{ "hospital_name": "La Palma Intercommunity Hospital", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "La Palma Intercommunity Hospital" ], "hospital_address": [ "7901 Walker Street La Palma, CA 90623" ], "license_information": { "license_number": "205253134", "state": "CA" }, "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Ayman Mousa" }, "type_2_npi": [ "1417965559", "1386947836" ], "standard_charge_information": [ { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 4", "code_information": [ { "code": "5644", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14390.43, "maximum": 15397.76, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15397.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 1", "code_information": [ { "code": "2511", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3970.07, "maximum": 4247.97, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4247.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 5515, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5515, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 3", "code_information": [ { "code": "2513", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6680.75, "maximum": 7148.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7148.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 4", "code_information": [ { "code": "2514", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10145.16, "maximum": 10855.32, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10855.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 1", "code_information": [ { "code": "5431", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4539.67, "maximum": 4857.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY", "code_information": [ { "code": "770", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9989, "minimum": 7725.46, "maximum": 18101.5176, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10089.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.02 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12923.2 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12986.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18101.52, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14585.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14045.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10589.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15983.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10180.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.02 } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 2", "code_information": [ { "code": "5642", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3745.55, "maximum": 4007.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4007.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 2", "code_information": [ { "code": "5432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5975.15, "maximum": 6393.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6393.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 3", "code_information": [ { "code": "5433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9671.72, "maximum": 10348.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 4", "code_information": [ { "code": "5434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17669.85, "maximum": 18906.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18906.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8449, "minimum": 5470.67, "maximum": 28970.18, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8534.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15435.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16005.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10984.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15311.38, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12336.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11880.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8956.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13519.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5470.67 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15435.51 } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 4", "code_information": [ { "code": "1934", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18754.23, "maximum": 20067.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20067.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 2", "code_information": [ { "code": "1932", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9819.71, "maximum": 10507.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10507.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 1", "code_information": [ { "code": "5641", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2923.44, "maximum": 3128.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3128.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 3", "code_information": [ { "code": "5643", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6403.11, "maximum": 6851.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6851.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9584, "minimum": 5936, "maximum": 17366.8241, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9680.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15828.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15445.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12459.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17366.82, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13993.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13475.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10159.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15334.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7834.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15828.5 } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16708, "minimum": 9184.57, "maximum": 30275.0591, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16708.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16875.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26034.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23909.61 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21720.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16708.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30275.06, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24393.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23491.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17710.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16708.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16708.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26732.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9184.57 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16708.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26034.62 } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 8710.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8710.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26241, "minimum": 20141.42, "maximum": 47549.9966, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 26241.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26504.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 45102.79 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41955.48 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 34114.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 26241.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47550, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 38312.91, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 36895.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27816.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 26241.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26241.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41986.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35660.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 26241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45102.79 } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 2", "code_information": [ { "code": "7562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4969.75, "maximum": 5317.63, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5317.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 1", "code_information": [ { "code": "1451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3855.58, "maximum": 4125.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4125.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 3", "code_information": [ { "code": "1933", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13200.37, "maximum": 14124.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14124.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9293, "minimum": 9293.36, "maximum": 17557.23, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9386.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16165.34 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17557.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12081.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16839.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13568.31, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13066.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9850.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14869.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12960.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9293.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16165.34 } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 1", "code_information": [ { "code": "4691", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4013.54, "maximum": 4294.49, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4294.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 4", "code_information": [ { "code": "1454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10920.09, "maximum": 11684.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11684.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 1", "code_information": [ { "code": "7561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3331.89, "maximum": 3565.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3565.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 4", "code_information": [ { "code": "7564", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10975.22, "maximum": 11743.49, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11743.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 2", "code_information": [ { "code": "4692", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5463.76, "maximum": 5846.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11521, "minimum": 5758.1, "maximum": 20877.8096, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11521.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11637.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19206.87 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20730.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14978.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11521.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20877.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16822.08, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16199.89, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12213.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11521.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11521.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18435.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11521.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5758.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11522, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19206.87 } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 3", "code_information": [ { "code": "7563", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7029.52, "maximum": 7521.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7521.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 3", "code_information": [ { "code": "1453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6782.52, "maximum": 7257.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7257.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45078.63, "maximum": 48234.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48234.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 1", "code_information": [ { "code": "1901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6639.41, "maximum": 7104.17, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7104.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 2", "code_information": [ { "code": "1452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4873.28, "maximum": 5214.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5214.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8594.23, "maximum": 9195.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9195.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7920, "minimum": 3692.43, "maximum": 14351.9641, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7999.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11200.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12046.22 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10296.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14351.96, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11563.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11136.24, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8395.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12672.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3692.43 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7920.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11200.15 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9192, "minimum": 8532.58, "maximum": 16656.3208, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14707.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12248.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15220.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9284.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15220.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14772.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11949.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16656.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13420.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12924.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9743.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9192.23, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 3", "code_information": [ { "code": "4693", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8886.82, "maximum": 9508.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9508.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 3", "code_information": [ { "code": "1903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9493.2, "maximum": 10157.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10157.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 2", "code_information": [ { "code": "1902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 7828.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 3", "code_information": [ { "code": "7553", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5442.55, "maximum": 5823.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5823.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 4", "code_information": [ { "code": "4694", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17070.79, "maximum": 18265.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18265.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 4", "code_information": [ { "code": "1904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15137.17, "maximum": 16196.77, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16196.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7322, "minimum": 7322.33, "maximum": 23373.44, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7395.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11972.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11619.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9519.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13268.06, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10690.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10295.2, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7761.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11715.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10986.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7322.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11972.92 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21334, "minimum": 12150, "maximum": 38657.5342, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21334.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21547.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37631.07 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36444.48 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27734.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 21334.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38657.53, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31147.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 29995.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22614.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21334.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21334.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34134.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32424.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37631.07 } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15211.37, "maximum": 16276.17, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16276.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15727, "minimum": 10845.38, "maximum": 28497.9401, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15727.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15884.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27102.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25670.02 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20445.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15727.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28497.94, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22961.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22112.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16670.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15727.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15727.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25163.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18168.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27102.95 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7027, "minimum": 7027.53, "maximum": 12733.8844, "payers_information": [ { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12235.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7097.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12235.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11968.56 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9135.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12733.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10260.19, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9880.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7449.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11244.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9809.51 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 1", "code_information": [ { "code": "4011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10090.03, "maximum": 10796.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25746.65, "maximum": 27548.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27548.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19321, "minimum": 8167.96, "maximum": 35009.9782, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19321.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19514.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32287.75 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31897.82 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25117.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19321.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35009.98, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28208.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 27165.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20480.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19321.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19321.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30913.89, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33724.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19321.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32287.75 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6137, "minimum": 5850, "maximum": 26111.04, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6198.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9269.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7907.31 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 7978.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11121.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8960.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 8629.21, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6505.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9819.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7432.57 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6137.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9269.89 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 2", "code_information": [ { "code": "4012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13076.33, "maximum": 13991.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13991.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20322, "minimum": 14390.1, "maximum": 36825.1129, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20322.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20526.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35268.19 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36171.03 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26419.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20322.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36825.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29671.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28574.01, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21542.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20322.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20322.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32516.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24067.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20322.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35268.19 } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43950, "minimum": 19350, "maximum": 80691.3107, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 43950.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 44389.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 80691.31 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73319.35 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 57135.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 43950.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 79638.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64167.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 61794.32, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46587.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43950.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43950.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 70320.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64692.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43950.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80691.31 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52799, "minimum": 24612.44, "maximum": 108610, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 52799.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53327.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 91267.31 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90593.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 68638.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 52799.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 95671.93, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77086.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 74235.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55967.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52799.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52799.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 84478.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 108610 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91267.31 } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 2", "code_information": [ { "code": "7552", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2936.48, "maximum": 3142.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3142.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 3", "code_information": [ { "code": "4013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24086.53, "maximum": 25772.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25772.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12058, "minimum": 10800, "maximum": 56690.74, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12058.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12178.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20981.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22844.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15675.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12058.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21849.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17604.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16953.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12781.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12058.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12058.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19293.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16822.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12058.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20981.92 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13773, "minimum": 6750, "maximum": 41151.32, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13773.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13911.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23661.83 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23802.82 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17905.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13773.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24957.56, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20109.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19365.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14599.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13773.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13773.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22037.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19663.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23661.83 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 4", "code_information": [ { "code": "4014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45294.89, "maximum": 48465.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48465.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 1", "code_information": [ { "code": "7721", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3856.64, "maximum": 4126.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4126.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 1", "code_information": [ { "code": "7551", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2180.63, "maximum": 2333.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2333.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 2", "code_information": [ { "code": "7722", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4532.99, "maximum": 4850.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4850.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6412, "minimum": 6412.18, "maximum": 23488, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6476.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9677.74 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10332.73 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8335.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11618.87, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9361.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9015.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10259.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23488 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6412.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9677.74 } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7753", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8305.88, "maximum": 8887.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8887.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 4", "code_information": [ { "code": "7554", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8638.75, "maximum": 9243.46, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9243.46, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13928, "minimum": 8777.87, "maximum": 34200, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13928.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14068.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23907.86 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26030.85 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18107.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13928.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25239.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20336.33, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19584.16, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13928.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13928.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22286.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13928.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8777.87 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13929, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23907.86 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8093, "minimum": 8093.19, "maximum": 16812.64, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8174.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13500.29 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12623.86 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10521.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14664.86, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11816.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11379.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8578.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12949.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11915.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13500.29 } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7754", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19303.36, "maximum": 20654.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20654.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11773, "minimum": 7406.86, "maximum": 29420.2, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11773.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11891.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17816.55 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17358.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15305.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11773.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21334.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17189.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16554.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12480.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11773.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11773.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18838.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29420.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11773.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17816.55 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17072, "minimum": 10176, "maximum": 30935.4062, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17072.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17243.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29404.74 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28770.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22194.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 17072.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30935.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24925.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 24003.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18096.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17072.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17072.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27316.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13981.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29404.74 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6309, "minimum": 4452, "maximum": 11432.1798, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6372.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10305.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9295.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8201.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11432.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9211.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 8870.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6687.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10094.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4601.23 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6309.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10305.2 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11167, "minimum": 9486.02, "maximum": 20234.7308, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11167.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11278.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18802.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18317.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14517.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11167.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20234.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16303.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15700.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11837.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11167.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11167.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17867.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18601.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18802.32 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8845, "minimum": 6996, "maximum": 16028.807, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8934.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14566.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13843.85 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11499.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16028.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12915.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12437.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9376.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14153.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14566.97 } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 3", "code_information": [ { "code": "7723", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6860.97, "maximum": 7341.24, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7341.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 3", "code_information": [ { "code": "2803", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9753.98, "maximum": 10436.76, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10436.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18215, "minimum": 13287.98, "maximum": 33006.3954, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18215.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33006.4, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26594.56, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25610.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19308.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18215.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18215.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29144.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24574.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30651.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18215.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18215.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18397.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30651.4 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29941.62 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23680.09, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 1", "code_information": [ { "code": "2801", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4881.76, "maximum": 5223.48, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5223.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7751", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3288.43, "maximum": 3518.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3518.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 2", "code_information": [ { "code": "8112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4082.45, "maximum": 4368.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4368.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34942, "minimum": 18450, "maximum": 72315.12, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 34942.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35291.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58901.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57182.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 45425.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 34942.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63315.77, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 51016.02, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 49129.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37039.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34942.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34942.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55907.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47224 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34942.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58901.95 } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 4", "code_information": [ { "code": "2804", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19238.69, "maximum": 20585.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20585.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 1", "code_information": [ { "code": "0071", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55309.66, "maximum": 59181.34, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59181.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16466, "minimum": 7862.34, "maximum": 29837.6966, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16466.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16631.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28696.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28703.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21406.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16466.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29837.7, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24041.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23152.21, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17454.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16466.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16466.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26346.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18364.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16466.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28696.37 } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 4", "code_information": [ { "code": "7724", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18947.17, "maximum": 20273.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20273.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 1", "code_information": [ { "code": "8111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2829.41, "maximum": 3027.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3027.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 1", "code_information": [ { "code": "0521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4892.36, "maximum": 5234.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5234.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6780, "minimum": 5267.92, "maximum": 18507.12, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6848.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10965.68 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10659.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8814.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12286.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9899.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9533.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7187.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10848.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5267.92 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10965.68 } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7752", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4746.07, "maximum": 5078.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5078.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 3", "code_information": [ { "code": "8113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8023.9, "maximum": 8585.57, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8585.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 115078, "minimum": 115078, "maximum": 216338.1794, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 115078.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 116228.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 216338.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 185440.65 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 149601.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 115078.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 208521.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 168014.2, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 161799.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 121982.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 115078.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 115078.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 184125.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 115078.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 140080 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 115078, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 216338.18 } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 2", "code_information": [ { "code": "2802", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6415.73, "maximum": 6864.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6864.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 3", "code_information": [ { "code": "0073", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89273.14, "maximum": 95522.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 95522.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 4", "code_information": [ { "code": "0074", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 149835.59, "maximum": 160324.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 160324.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 4", "code_information": [ { "code": "8114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15162.61, "maximum": 16223.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16223.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 2", "code_information": [ { "code": "0522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6485.69, "maximum": 6939.69, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6939.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 2", "code_information": [ { "code": "0072", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66446.01, "maximum": 71097.23, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71097.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC", "code_information": [ { "code": "240", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27618, "minimum": 16335.92, "maximum": 50044.5046, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 27618.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27894.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 48086.53 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45453.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 35903.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 27618.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50044.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 40322.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 38831.44, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29275.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27618.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27618.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 44189.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24854.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 27618.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48086.53 } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 3", "code_information": [ { "code": "0523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9100.96, "maximum": 9738.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9738.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22134, "minimum": 22134.6, "maximum": 40107.9133, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22134.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22355.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35621.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34701.86 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28774.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 22134.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40107.91, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32316.53, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 31121.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23462.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22134.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22134.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35415.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24937 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22134.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35621.54 } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 4", "code_information": [ { "code": "0524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15262.26, "maximum": 16330.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16330.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CCMCC", "code_information": [ { "code": "241", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13631, "minimum": 13631.3, "maximum": 37675.04, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13631.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13767.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24931.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22555.32 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17720.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13631.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24699.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19901.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19165.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13631.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13631.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21810.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19988.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13631.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24931.61 } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11683, "minimum": 10261.5, "maximum": 21169.9584, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11800.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19205.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19042.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15188.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21169.96, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17057.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16426.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12384.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18693.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10261.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11683.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19205.22 } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 3", "code_information": [ { "code": "3053", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18500.87, "maximum": 19795.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19795.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC", "code_information": [ { "code": "616", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33694, "minimum": 22069.54, "maximum": 64036.72, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33694.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34031.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 63819.25 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64036.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 43802.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 33694.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 61054.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49194.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 47374.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35716.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33694.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33694.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53911.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29283 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33694.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63819.25 } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 2", "code_information": [ { "code": "2262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8216.84, "maximum": 8792.02, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8792.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41379, "minimum": 41379.3, "maximum": 74979.346, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 41379.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41793.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 74051.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69620.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 53793.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 41379.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 74979.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 60413.82, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 58179.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43862.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 41379.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41379.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 66206.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68796.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 41379.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74051.8 } ] } ] }, { "description": "Amputation Of Toe", "code_information": [ { "code": "28820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12300, "discounted_cash": 4187, "minimum": 327.36, "maximum": 12300, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 343.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 350.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 3", "code_information": [ { "code": "2263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12875.97, "maximum": 13777.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13777.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 2", "code_information": [ { "code": "3052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12581.27, "maximum": 13461.96, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13461.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 1", "code_information": [ { "code": "2261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6668.03, "maximum": 7134.79, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC", "code_information": [ { "code": "239", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47378, "minimum": 33635.9, "maximum": 85849.4252, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 47378.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85849.43, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69172.27, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 66613.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50221, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 47378.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47378.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75805.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47197.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83169.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 47378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 47378.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47852.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 83169.78 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77775.4 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 61591.75, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8729, "minimum": 7650, "maximum": 17989.1, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8816.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14545.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15788.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11348.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15817.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12745.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12273.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9253.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13967.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8801.73 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8729.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14545.51 } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC", "code_information": [ { "code": "617", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18266, "minimum": 16735.94, "maximum": 33099.7496, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18266.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18449.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31894.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32109.78 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23747.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18266.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33099.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26669.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25683.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19363.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18266.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18266.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29227.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18266.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18129.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18267, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31894.76 } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 6695.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6695.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 1", "code_information": [ { "code": "3051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9407.33, "maximum": 10065.84, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10065.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANES ADDL 15 MIN", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7123.28, "minimum": 58.47, "maximum": 7123.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.56 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12910, "minimum": 12910.09, "maximum": 29404.42, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12910.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13039.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20787.08 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21057.03 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16783.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12910.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23393.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18848.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 18151.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13684.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12910.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12910.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20656.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16026.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12910.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20787.08 } ] } ] }, { "description": "Ankle arthroscopysurgery", "code_information": [ { "code": "29897", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28968.8, "discounted_cash": 4187, "minimum": 375.28, "maximum": 28968.76, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 28968.76, "discounted_cash": 4187, "minimum": 375.28, "maximum": 28968.76, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 4", "code_information": [ { "code": "3054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31219.94, "maximum": 33405.34, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33405.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 2", "code_information": [ { "code": "1982", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4834.06, "maximum": 5172.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5172.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 1", "code_information": [ { "code": "1981", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3984.92, "maximum": 4263.86, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4263.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 2", "code_information": [ { "code": "0592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7339.07, "maximum": 7852.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7852.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "618", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13954, "minimum": 13954.75, "maximum": 34071.32, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13954.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14094.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20559.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18793.4 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18141.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13954.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25286.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20373.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19620.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14792.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13954.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13954.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22327.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16483.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13954.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20559.21 } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 2", "code_information": [ { "code": "5472", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8566.24, "maximum": 9165.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9165.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 4", "code_information": [ { "code": "1984", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10894.65, "maximum": 11657.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11657.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 4", "code_information": [ { "code": "0594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16561.94, "maximum": 17721.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17721.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 4", "code_information": [ { "code": "2264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21704.49, "maximum": 23223.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23223.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5474", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25639.21, "maximum": 27433.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27433.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 3", "code_information": [ { "code": "0593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10738.81, "maximum": 11490.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5471", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4360.09, "maximum": 4665.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4665.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22324, "minimum": 10273.08, "maximum": 41245.17, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22324.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22547.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39080.83 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41245.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 29021.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 22324.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40451.94, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32593.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 31388.2, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23663.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22324.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22324.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35719.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31332 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22324.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39080.83 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 2", "code_information": [ { "code": "5662", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3248.78, "maximum": 3476.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3476.19, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 66041, "minimum": 17995.8, "maximum": 119666.3464, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 66041.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 66701.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 110096.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110911.01 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 85853.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 66041.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 119666.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 96419.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 92853.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 70003.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 66041.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66041.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 105665.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66041.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17995.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 66041, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110096.05 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13254.22, "maximum": 14182.02, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14182.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4224.43, "minimum": 146.17, "maximum": 4224.43, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6022.96, "maximum": 6444.57, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2333", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15997.97, "maximum": 17117.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17117.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2331", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8727.8, "maximum": 9338.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9338.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7120, "minimum": 7120.07, "maximum": 24605.36, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7191.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11530.4 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11295.46 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9256.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12901.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10395.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10010.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7547.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11392.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7873.85 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7120.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11530.4 } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40714, "minimum": 6750, "maximum": 73774.4384, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 40714.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41121.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 68701.88 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67287.34 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 52928.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 40714.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73774.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59442.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 57244.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43157.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40714.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40714.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65142.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8180.36 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40714.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68701.88 } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2342", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9012.97, "maximum": 9643.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9643.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2332", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11244.48, "maximum": 12031.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12031.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 1", "code_information": [ { "code": "0591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4225.56, "maximum": 4521.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4521.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2344", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21609.08, "maximum": 23121.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23121.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2343", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13392.24, "maximum": 14329.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14329.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2341", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7065.57, "maximum": 7560.16, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7560.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5473", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13219.02, "maximum": 14144.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14144.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 3", "code_information": [ { "code": "1413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6672.27, "maximum": 7139.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7139.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23271, "minimum": 22950, "maximum": 42168.5378, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23271.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23504.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 40913.67 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36350.63 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30253.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23271.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42168.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33976.86, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 32720.18, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24668.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23271.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23271.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37234.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34688.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23271.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40913.67 } ] } ] }, { "description": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14863, "minimum": 13500, "maximum": 31191.3, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14863.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15012.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24986.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24485.63 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19323.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14863.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26933.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21701.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 20898.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15755.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14863.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14863.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23782.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31191.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24986.1 } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2268.08, "maximum": 2426.85, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2426.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6846, "minimum": 6213.69, "maximum": 18594.44, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6914.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11102.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10648.25 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8900.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12405.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9995.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9625.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7257.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10954.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6213.69 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6846.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11102.73 } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11344, "minimum": 8550, "maximum": 20556.2702, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11344.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11457.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18556.29 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18010.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14747.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11344.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20556.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16563, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15950.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12025.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11344.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11344.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18151.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20062.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11344.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18556.29 } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2334", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24117.27, "maximum": 25805.48, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25805.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 3", "code_information": [ { "code": "0083", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 42705.07, "maximum": 45694.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45694.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 2", "code_information": [ { "code": "1412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4806.49, "maximum": 5142.94, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5142.94, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18000, "maximum": 35641.9, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29006.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22103.89 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23255.4 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29006.8 } ] } ] }, { "description": "ASTHMA - SOI : 1", "code_information": [ { "code": "1411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3243.91, "maximum": 3470.98, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3470.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11839, "minimum": 8910.18, "maximum": 21453.4639, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11839.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21453.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17285.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16646.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12550.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11839.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11839.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18943.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15400.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19208.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11839.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11958.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19208.52 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18139.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15391.56, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "ASTHMA - SOI : 4", "code_information": [ { "code": "1414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11195.72, "maximum": 11979.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11979.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14676, "minimum": 9000, "maximum": 33868.36, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14822.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23665.14 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23162.08 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19078.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26592.91, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21426.96, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 20634.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15556.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23481.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20822.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23665.14 } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 1", "code_information": [ { "code": "0081", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29173.95, "maximum": 31216.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31216.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 2", "code_information": [ { "code": "0082", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 34562.44, "maximum": 36981.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36981.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 1", "code_information": [ { "code": "0491", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8313.3, "maximum": 8895.23, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8895.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 4", "code_information": [ { "code": "0084", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 65108.16, "maximum": 69665.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69665.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56994, "minimum": 56994.9, "maximum": 103274.7769, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 56994.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 57564.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 99665.36 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99945.63 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 74093.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 56994.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 103274.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83212.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 80134.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60414.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 56994.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56994.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91191.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59905.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56994.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99665.36 } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 4", "code_information": [ { "code": "0494", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25716.97, "maximum": 27517.16, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27517.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 2", "code_information": [ { "code": "0492", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11038.82, "maximum": 11811.54, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11811.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52249, "minimum": 52249.56, "maximum": 99945.63, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 52249.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 52772.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 99665.36 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99945.63 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 67924.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 52249.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 94676.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 76284.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 73462.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55384.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52249.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52249.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83599.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79904.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99665.36 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25030, "minimum": 24750, "maximum": 45354.5412, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25280.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39582.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38577.04 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32539.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45354.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36543.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 35192.32, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26531.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40048.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30377.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39582.8 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33999, "minimum": 33999.9, "maximum": 61607.8188, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34339.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 60247.68 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58616.32 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 44199.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 61607.82, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49639.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 47803.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54399.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39354.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33999.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60247.68 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 4", "code_information": [ { "code": "7584", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22778.37, "maximum": 24372.86, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24372.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20222, "minimum": 9752, "maximum": 36643.6049, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20222.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20424.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29663.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27210.39 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26289.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20222.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36643.6, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29525.2, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28433.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21436.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20222.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20222.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32356.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14642.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20222.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29663.98 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 2", "code_information": [ { "code": "7582", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4174.67, "maximum": 4466.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4466.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19506, "minimum": 14400, "maximum": 35345.3431, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19506.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19701.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32560.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31852.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25358.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19506.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35345.34, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28479.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 27425.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20676.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19506.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19506.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31210.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26578.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19506.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32560.2 } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR", "code_information": [ { "code": "518", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36078, "minimum": 23602.36, "maximum": 65374.6588, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 36078.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 36439.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 59179.35 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59087.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 46902.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 36078.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 65374.66, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 52674.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 50726.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 38243.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 36078.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36078.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 57725.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39301.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 36078.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59179.35 } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC", "code_information": [ { "code": "461", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53114, "minimum": 31950, "maximum": 110325.29, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 53114.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53646.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 101329.78 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110325.29 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 69049.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 53114.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 96244.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77547.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 74679.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56301.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 53114.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53114.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 84983.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 81239.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 53114.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101329.78 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 3", "code_information": [ { "code": "7583", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6793.12, "maximum": 7268.64, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7268.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 3", "code_information": [ { "code": "0493", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15618.45, "maximum": 16711.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16711.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11587, "minimum": 8519.6, "maximum": 20997.0936, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11703.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20848.17 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20078.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15064.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20997.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16918.19, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16292.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12283.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18540.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16714.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11587.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20848.17 } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "410", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15570, "minimum": 14850, "maximum": 28214.4346, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15570.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15726.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25611.91 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25325.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20242.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15570.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28214.43, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22733.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21892.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16505.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15570.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15570.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24913.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24722.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15570.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25611.91 } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "409", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21195, "minimum": 20700, "maximum": 38406.8802, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21195.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21407.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34617.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31669.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27554.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 21195.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38406.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30945.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 29801.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22467.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21195.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21195.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33913.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32312.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21195.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34617.61 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25030, "minimum": 16076.32, "maximum": 45354.5412, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25280.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39582.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35268.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32539.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45354.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36543.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 35192.32, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26531.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40048.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23229.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25030.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39582.8 } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 4", "code_information": [ { "code": "7534", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13656.21, "maximum": 14612.14, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14612.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23885, "minimum": 23400, "maximum": 43280.0911, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23885.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24124.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38615.19 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38568.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31050.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23885.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43280.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34872.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 33582.68, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25318.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23885.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23885.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38216.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23771.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23885.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38615.19 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 1", "code_information": [ { "code": "7581", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3371.12, "maximum": 3607.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3607.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "408", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34440, "minimum": 33750, "maximum": 69559.9, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69559.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57813.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 34440.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34785.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 57813.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60226.26 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 44772.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 34440.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62406.48, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50283.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 48423.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36507.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34440.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34440.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55105.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34440.66, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12790, "minimum": 9795.18, "maximum": 23176.984, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12790.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12918.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21564.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21867.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16628.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12790.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23176.98, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18674.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17983.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13558.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12790.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12790.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20465.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17289.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12790.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21564.8 } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 1", "code_information": [ { "code": "7531", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3406.1, "maximum": 3644.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3644.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7311, "minimum": 4646.55, "maximum": 17498.22, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7384.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12291.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11826.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9505.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13249.04, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10675.27, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10280.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7750.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11698.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4646.55 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7311.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12291.6 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33381, "minimum": 33381.68, "maximum": 60487.6042, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33381.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33715.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 56785.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54511.39 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 43396.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 33381.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60487.6, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 48737.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 46934.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35384.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33381.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33381.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53410.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53275.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33381.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56785.1 } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 3", "code_information": [ { "code": "0563", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10472.73, "maximum": 11205.82, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11205.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 3", "code_information": [ { "code": "7533", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 7828.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC", "code_information": [ { "code": "462", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25800, "minimum": 9900, "maximum": 47287.3405, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25800.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26059.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 47287.34 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46053.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 33541.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 25800.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46751.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37669.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 36276.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27349.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25800.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25800.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41281.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25800.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28340.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25801, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47287.34 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18158, "minimum": 14850, "maximum": 32902.6765, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18158.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18339.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29322.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30160.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23605.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18158.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32902.68, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26510.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25530.44, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19247.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18158.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18158.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29053.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19974.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18158.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29322.18 } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 1", "code_information": [ { "code": "1381", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2414.91, "maximum": 2583.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2583.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 2", "code_information": [ { "code": "1322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4672.92, "maximum": 5000.02, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5000.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Biopsy/Removal Lymph Nodes", "code_information": [ { "code": "38510", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13125, "discounted_cash": 5011, "minimum": 207.2, "maximum": 13125, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 217.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 7015.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7316.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7045.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 221.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 1", "code_information": [ { "code": "1321", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3163.34, "maximum": 3384.77, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3384.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6815, "minimum": 5638.83, "maximum": 12350.1209, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6883.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11502.33 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11243.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8860.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12350.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9950.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9582.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7224.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10905.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5638.83 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6815.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11502.33 } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 1", "code_information": [ { "code": "3631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9470.93, "maximum": 10133.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10133.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 2", "code_information": [ { "code": "7532", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4274.32, "maximum": 4573.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4573.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 4", "code_information": [ { "code": "1324", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10990.06, "maximum": 11759.36, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11759.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 2", "code_information": [ { "code": "3632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16578.9, "maximum": 17739.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17739.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8343, "minimum": 6633.5, "maximum": 15597.24, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8426.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13781 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13296.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10846.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15117.77, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12180.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11730.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8843.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13349.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6633.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13781 } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 2", "code_information": [ { "code": "0562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6725.27, "maximum": 7196.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7196.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 3", "code_information": [ { "code": "1383", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6974.4, "maximum": 7462.61, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 3", "code_information": [ { "code": "1323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7546.85, "maximum": 8075.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8075.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 4", "code_information": [ { "code": "0564", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17996.26, "maximum": 19256, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19256, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 4", "code_information": [ { "code": "1384", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13157.96, "maximum": 14079.02, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14079.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4859.5, "maximum": 5199.66, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5199.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20846, "minimum": 15300, "maximum": 38138.4, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20846.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21055.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33806.87 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31690.71 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27100.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20846.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37774.17, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30436.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 29310.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22097.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20846.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20846.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33354.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38138.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20846.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33806.87 } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18827, "minimum": 9900, "maximum": 36075.2, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18827.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19016.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32778.16 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27247.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24476.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18827.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34116.23, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27488.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26472.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19957.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18827.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18827.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30124.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36075.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18827.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32778.16 } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 3", "code_information": [ { "code": "3633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22764.59, "maximum": 24358.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24358.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 4", "code_information": [ { "code": "3634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27154.46, "maximum": 29055.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29055.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 1", "code_information": [ { "code": "8421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10311.59, "maximum": 11033.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11033.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 3", "code_information": [ { "code": "2013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7540.49, "maximum": 8068.32, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8068.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 2", "code_information": [ { "code": "1382", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3832.26, "maximum": 4100.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4100.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 4", "code_information": [ { "code": "8424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 92524.47, "maximum": 99001.18, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99001.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 1", "code_information": [ { "code": "1911", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7807.64, "maximum": 8354.17, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8354.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9689, "minimum": 8724.21, "maximum": 21605.8, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9786.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15962.24 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15492.62 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12596.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17556.98, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14146.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13623.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10270.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15502.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8724.21 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9689.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15962.24 } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 2", "code_information": [ { "code": "1962", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4660.2, "maximum": 4986.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 1", "code_information": [ { "code": "1921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8493.52, "maximum": 9088.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9088.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 3", "code_information": [ { "code": "1963", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7462.04, "maximum": 7984.38, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7984.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 4", "code_information": [ { "code": "1924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25280.2, "maximum": 27049.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27049.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 2", "code_information": [ { "code": "8422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16502.58, "maximum": 17657.76, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17657.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 3", "code_information": [ { "code": "8423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 32270.5, "maximum": 34529.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34529.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15324, "minimum": 9000, "maximum": 27768.4289, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15324.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15477.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27053.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25940.24 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19922.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15324.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27768.43, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22374.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21546.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16244.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15324.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15324.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24519.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27495.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27053.42 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44485, "minimum": 14850, "maximum": 80607.9978, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 44485.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 44930.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 76812.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77380.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 57831.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 44485.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 80608, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64949.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 62546.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47154.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 44485.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44485.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 71177.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63897.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 44485.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76812.62 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 4", "code_information": [ { "code": "2014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13236.41, "maximum": 14162.96, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14162.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 2", "code_information": [ { "code": "1772", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14638.92, "maximum": 15663.64, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15663.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 4", "code_information": [ { "code": "1964", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14134.31, "maximum": 15123.71, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15123.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 1", "code_information": [ { "code": "1961", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3610.7, "maximum": 3863.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3863.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 2", "code_information": [ { "code": "1912", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9237.71, "maximum": 9884.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9884.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 4", "code_information": [ { "code": "1774", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28401.14, "maximum": 30389.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30389.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6472, "minimum": 5850, "maximum": 12596.5, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11631.12 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11788.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8413.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11727.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9449.54, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9100.04, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6860.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10355.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9325.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6472.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11631.12 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4765, "minimum": 4765.53, "maximum": 8635.1404, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5051.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7624.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5847.54 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7293.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 4813.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7293.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7114.47 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 6195.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 8635.14, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 6957.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 6700.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 4765.53, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 3", "code_information": [ { "code": "1913", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12200.69, "maximum": 13054.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13054.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30400, "minimum": 21600, "maximum": 55085.4161, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30400.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30704.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46324.69 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43825.92 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 39520.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 30400.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55085.42, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44384.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 42742.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32224.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30400.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30400.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48640.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37140.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30400.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46324.69 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 1", "code_information": [ { "code": "2011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3796.22, "maximum": 4061.96, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4061.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 2", "code_information": [ { "code": "2012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5121.34, "maximum": 5479.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 3", "code_information": [ { "code": "1923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15382.05, "maximum": 16458.79, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16458.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18459, "minimum": 13500, "maximum": 33448.9583, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18459.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18644.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31333.35 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30448.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18459.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33448.96, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26951.15, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25954.32, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19567.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18459.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18459.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29535.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33085.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18459.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31333.35 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7442, "minimum": 6331.76, "maximum": 13485.8825, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7516.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12207.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12049.46 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9675.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13485.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10866.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10464.21, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7889.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11908.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6331.76 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7442.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12207.39 } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 1", "code_information": [ { "code": "1771", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9740.2, "maximum": 10422.01, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10422.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15457, "minimum": 8681.26, "maximum": 28008.7182, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15457.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15611.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24725.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24865.86 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20094.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15457.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28008.72, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22567.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21733.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16384.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15457.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15457.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24731.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19823 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15457.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24725.21 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31456, "minimum": 22307.9, "maximum": 70465.1, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31456.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31771.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 56243.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53640.89 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 40893.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 31456.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56999.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45926.42, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 44227.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33343.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31456.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31456.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50330.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70465.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31456.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56243.5 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11910, "minimum": 8282.42, "maximum": 21581.3911, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11910.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12029.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19911.94 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19451.94 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15483.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11910.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21581.39, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17388.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16745.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12624.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11910.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11910.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19056.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11438.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19911.94 } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 3", "code_information": [ { "code": "1773", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18511.47, "maximum": 19807.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19807.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9135, "minimum": 6679.98, "maximum": 16554.3233, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9227.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15296.81 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15251.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11876.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16554.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13338.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12845.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9684.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14617.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10570.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9135.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15296.81 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15973, "minimum": 9000, "maximum": 36077.32, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15973.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16133.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25062.06 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26621.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20765.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15973.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28943.95, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23321.28, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22458.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16931.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15973.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15973.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25557.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20093.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15973.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25062.06 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5824, "minimum": 5378.84, "maximum": 10553.994, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5882.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9238.52 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8947.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 7571.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10553.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8503.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 8189.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6173.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9319.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5378.84 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5824.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9238.52 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 2", "code_information": [ { "code": "2002", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5660.93, "maximum": 6057.2, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6057.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57728, "minimum": 27900, "maximum": 104604.1507, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 57728.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 58305.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 102282.53 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100482.82 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 75047.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 57728.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104604.15, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 84283.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 81166.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61192.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57728.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57728.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 92365.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 44932.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 57728.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102282.53 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 1", "code_information": [ { "code": "2001", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3867.24, "maximum": 4137.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4137.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 4", "code_information": [ { "code": "1914", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18727.73, "maximum": 20038.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20038.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 3", "code_information": [ { "code": "2003", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8622.85, "maximum": 9226.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9226.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC", "code_information": [ { "code": "259", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19715, "minimum": 10800, "maximum": 38383.04, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19912.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29023.31 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30202.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25629.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35723.92, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28784.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 27719.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20898.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31544.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23268.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19715.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29023.31 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "216", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 93754, "minimum": 48150, "maximum": 169883.462, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 93754.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 94692.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 159359.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 157034.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 121881.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 93754.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 169883.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 136881.82, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 131819.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 99379.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 93754.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 93754.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 150007.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 136885 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 93754.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 159359.89 } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 2", "code_information": [ { "code": "1922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10796.06, "maximum": 11551.78, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11551.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "221", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 48508, "minimum": 13950, "maximum": 87897.9456, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 48993.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 75833.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75215.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 63061.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 87897.95, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 70822.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 68203.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51419.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 77614.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52039.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 48508.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75833.45 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 4", "code_information": [ { "code": "2004", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15253.78, "maximum": 16321.54, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16321.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1623", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 57853.9, "maximum": 61903.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61903.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 68449, "minimum": 37350, "maximum": 124031.3275, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 68449.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 69134.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 116690.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 113841.26 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 88984.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 68449.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 124031.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 99936.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 96240.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 72557, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 68449.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 68449.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 109519.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 68449.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77665.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 68450, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116690.98 } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1624", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 80771.14, "maximum": 86425.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86425.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "217", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63154, "minimum": 23400, "maximum": 114435.2836, "payers_information": [ { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62639 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106633.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 63785.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 106633.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102992.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 82100.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 114435.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 92205.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 88794.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66943.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 101046.61, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 4", "code_information": [ { "code": "2054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15093.7, "maximum": 16150.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16150.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "218", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63154, "minimum": 10350, "maximum": 114435.2836, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 63785.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98235.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92174.24 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 82100.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 114435.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 92205.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 88794.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66943.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 101046.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 78758.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 63154.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98235.41 } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 2", "code_information": [ { "code": "2052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5360.93, "maximum": 5736.2, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5736.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "219", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 73677, "minimum": 38250, "maximum": 133502.8871, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 73677.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 74413.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 127762.34 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 124769.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 95780.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 73677.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 133502.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 107568.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 103589.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 78097.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 73677.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 73677.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 117883.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 90723.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 73677.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 127762.34 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18958, "minimum": 5400, "maximum": 34353.0557, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18958.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19148.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30268.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29257.19 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24646.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18958.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34353.06, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27679.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26655.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20096.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18958.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18958.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30333.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26842.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18958.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30268.32 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "220", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51300, "minimum": 25200, "maximum": 92956.1436, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 51813.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 87459.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84859.13 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 66690.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 92956.14, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 74898.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 72128.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54378.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 82080.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62512.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 51300.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87459.62 } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 3", "code_information": [ { "code": "2053", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8170.19, "maximum": 8742.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1621", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38042.75, "maximum": 40705.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40705.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 48537.74, "maximum": 51935.38, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51935.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1622", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 44276.14, "maximum": 47375.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47375.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 1", "code_information": [ { "code": "3831", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3744.27, "maximum": 4006.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4006.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 71005.5, "maximum": 75975.89, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75975.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5 } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31937.63, "maximum": 34173.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34173.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 4", "code_information": [ { "code": "3834", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14332.55, "maximum": 15335.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15335.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARE OF MISCARRIAGE", "code_information": [ { "code": "59820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10815, "discounted_cash": 4143, "minimum": 241.91, "maximum": 10815, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10815, "discounted_cash": 4143, "minimum": 241.91, "maximum": 10815, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36891.48, "maximum": 39473.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39473.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13983, "minimum": 10276.62, "maximum": 25337.8664, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13983.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14123.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24259.57 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24068.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18178.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13983.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25337.87, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20415.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19660.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14822.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13983.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13983.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22373.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15137.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13983.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24259.57 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 37351, "minimum": 21150, "maximum": 67680.7549, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 37351.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 37724.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 64210.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63125.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 48556.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 37351.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 67680.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 54533.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 52516.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39592.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 37351.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 37351.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 59762.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51480.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37351.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64210.59 } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 1", "code_information": [ { "code": "2051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4035.8, "maximum": 4318.31, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4318.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23846, "minimum": 7540, "maximum": 30999.995, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23846.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24084.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30416.93 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28668.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23846.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25276.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23846.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23846.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17360.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23846.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30416.93 } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 3", "code_information": [ { "code": "3833", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7731.31, "maximum": 8272.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8272.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23229, "minimum": 8550, "maximum": 42092.4701, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23229.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23462.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37561.72 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37206.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30198.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23229.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42092.47, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33915.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 32661.16, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24623.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23229.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23229.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37167.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32787 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37561.72 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9561, "minimum": 7540, "maximum": 14423.3159, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9657.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14423.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14016.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12429.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10135.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9087.97 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9561.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14423.32 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 1", "code_information": [ { "code": "5401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5389.76, "maximum": 5767.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5767.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 2", "code_information": [ { "code": "5392", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6779.76, "maximum": 7254.34, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7254.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 4", "code_information": [ { "code": "5404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21052.9, "maximum": 22526.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22526.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16160, "minimum": 7540, "maximum": 28307.41, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16160.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16322.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26681.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28307.41 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21008.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16160.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17130.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16160.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16160.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16160.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26681.9 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16628.73, "maximum": 17792.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17792.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8459.6, "maximum": 9051.77, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9051.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7292, "minimum": 7292.75, "maximum": 13214.463, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7365.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11779.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11708.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9480.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13214.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10647.42, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10253.61, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7730.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11668.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7816.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11779.73 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25156, "minimum": 15436.76, "maximum": 45584.4478, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25156.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25408.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42168.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39544.62 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32704.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 25156.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45584.45, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36729.19, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 35370.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26666.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25156.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25156.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40251.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25156.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18598.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25157, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42168.59 } ] } ] }, { "description": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 412401, "minimum": 55350, "maximum": 747270.6664, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 412401.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 416525.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 622717.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 596125.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 536121.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 412401.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 747270.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 602105.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 579835.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 437145.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 412401.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 412401.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 659841.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 412401.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 433198 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 412401, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 622717.37 } ] } ] }, { "description": "CHEST PAIN - SOI : 4", "code_information": [ { "code": "2034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9476.23, "maximum": 10139.57, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10139.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34412, "minimum": 34200, "maximum": 62354.6165, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 34412.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34756.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 57855.08 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57038.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 44735.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 34412.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62354.62, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50241.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 48383.33, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36476.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34412.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34412.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55059.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34412.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46384.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57855.08 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20140, "minimum": 20140.69, "maximum": 36494.9303, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20140.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20342.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32662.58 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31969.01 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26182.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20140.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36494.93, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29405.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28317.81, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21349.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20140.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20140.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32225.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26777.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20140.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32662.58 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 2", "code_information": [ { "code": "2632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11931.43, "maximum": 12766.63, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12766.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 2", "code_information": [ { "code": "3832", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5117.1, "maximum": 5475.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5475.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13430, "minimum": 12600, "maximum": 27096.9, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13564.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22624.87 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21668.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17459.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24335.21, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19607.84, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 18882.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14235.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21488.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13430.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27096.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13430, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22624.87 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46491, "minimum": 31950, "maximum": 84241.7282, "payers_information": [ { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80204.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 46491.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46955.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 80204.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79590.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 60438.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 46491.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 84241.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 67876.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 65366.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49280.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46491.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46491.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74385.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46491, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46491.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52538.5 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7406.92, "maximum": 7925.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7925.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8732, "minimum": 6812.39, "maximum": 17370.78, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8819.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14543.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14314.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11352.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15823.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12749.29, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12277.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9256.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13971.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6812.39 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14543.85 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 4", "code_information": [ { "code": "2634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27036.79, "maximum": 28929.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28929.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 2", "code_information": [ { "code": "5402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6800.75, "maximum": 7276.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12433.91, "maximum": 13304.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13304.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 28530, "minimum": 11250, "maximum": 51697.1573, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 28530.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 28815.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 47838.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47819.22 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 37089.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 28530.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 51697.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41654.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 40113.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30242.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 28530.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 28530.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 45648.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32886 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 28530.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47838.84 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8466, "minimum": 8466.21, "maximum": 15340.7725, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8550.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14185.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13737.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11006.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15340.77, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12360.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11903.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8974.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13545.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9581.72 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8466.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14185.54 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 1", "code_information": [ { "code": "5391", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5511.04, "maximum": 5896.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5896.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7221, "minimum": 7221.2, "maximum": 13084.8144, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7293.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11500.67 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10832.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9387.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13084.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10542.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10153.01, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7654.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11553.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7928.72 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7221.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11500.67 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23714, "minimum": 7200, "maximum": 42970.6559, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23714.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23951.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39090.74 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39813.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30828.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23714.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42970.66, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34623.16, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 33342.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25137.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23714.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23714.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37943.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28098.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23714.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39090.74 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10632, "minimum": 9450, "maximum": 31933.16, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10632.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17993.23 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17500.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13822.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10632.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19266.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15523.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14949.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11270.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10632.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10632.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17012.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14456.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10632.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17993.23 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 4", "code_information": [ { "code": "5394", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24337.19, "maximum": 26040.79, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26040.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 3", "code_information": [ { "code": "5403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9359.2, "maximum": 10014.34, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10014.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9570, "minimum": 7540, "maximum": 14938.4933, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9666.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14938.49 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13834.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12442.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10145.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11848.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9570.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14938.49 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 2", "code_information": [ { "code": "0952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8045.1, "maximum": 8608.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8608.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10537, "minimum": 7540, "maximum": 17882.6, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10537.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10642.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17882.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16570.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13698.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10537.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11169.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10537.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10537.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10953.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17882.6 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7744", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15091.58, "maximum": 16147.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16147.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5846.45, "maximum": 6255.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6255.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 3", "code_information": [ { "code": "5393", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11858.17, "maximum": 12688.24, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12688.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10760, "minimum": 10760.66, "maximum": 19498.3159, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10760.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10868.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17983.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17361.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13988.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10760.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19498.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15710.56, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15129.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10760.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10760.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17217.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11974.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17983.32 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8527, "minimum": 8527.27, "maximum": 31972.1, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8612.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13521.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13529.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11085.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15451.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12449.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11989.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9038.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13643.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8692.01 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8527.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13521.76 } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11078, "minimum": 7540, "maximum": 17532.5435, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11078.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11189.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17532.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17007.1 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14401.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11078.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11743.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11078.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11078.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16212.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11078.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17532.54 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19143, "minimum": 17853.9, "maximum": 34688.4388, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19143.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19335.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31774.23 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31527.29 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24886.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19143.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34688.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27949.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26916.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20292.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19143.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19143.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30629.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17853.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31774.23 } ] } ] }, { "description": "CHEST PAIN - SOI : 1", "code_information": [ { "code": "2031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4004, "maximum": 4284.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4284.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 3", "code_information": [ { "code": "6613", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11209.5, "maximum": 11994.17, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11994.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39025.46, "maximum": 41757.24, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41757.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 104166, "minimum": 56250, "maximum": 188748.8101, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 104166.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 105207.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 179881.12 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 174273.01 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 135415.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 104166.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 188748.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 152082.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 146457.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 110415.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 104166.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 104166.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 166665.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 104166.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 144217 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 104166, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 179881.12 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31938, "minimum": 25650, "maximum": 57872.0909, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31938.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32257.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 45183.7 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49194.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 41519.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 31938.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57872.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46629.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 44905.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33854.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31938.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31938.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51101.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36225.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31938.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45183.7 } ] } ] }, { "description": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14975, "minimum": 14921.2, "maximum": 27135.7147, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14975.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15125.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.72 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25241.25 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19468.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14975.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27135.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21864.32, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21055.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15874.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14975.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14975.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23960.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14921.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14975.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.72 } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC", "code_information": [ { "code": "837", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46258, "minimum": 24631.32, "maximum": 83819.9309, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 60135.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 46258.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83819.93, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 67537.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 65039.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49033.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46258.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46258.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74013.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 60680.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 82679.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 46258.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 46258.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46720.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 82679.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78377.31 } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 3", "code_information": [ { "code": "0573", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9804.86, "maximum": 10491.2, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10491.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 1", "code_information": [ { "code": "2631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9312.98, "maximum": 9964.89, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9964.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7741", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2749.9, "maximum": 2942.39, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2942.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT", "code_information": [ { "code": "838", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20338, "minimum": 17038.02, "maximum": 36852.764, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20338.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20541.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33489.83 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32388.08 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26439.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20338.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36852.76, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29693.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28595.47, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21558.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20338.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20338.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32541.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18544.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20338.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33489.83 } ] } ] }, { "description": "CONIZATION OF CERVIX", "code_information": [ { "code": "57522", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13518.75, "discounted_cash": 4143, "minimum": 321.98, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13518.8, "discounted_cash": 4143, "minimum": 321.98, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 3", "code_information": [ { "code": "2633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16322.36, "maximum": 17464.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17464.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7743", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5959.88, "maximum": 6377.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6377.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14198, "minimum": 12266.4, "maximum": 38171.82, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22718.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14198.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12266.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22628.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14198.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14340.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22628.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21084.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18458.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14198.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25728.55, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20730.51, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19963.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15050.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14198.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14199, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14198.98, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 4", "code_information": [ { "code": "3464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21898.49, "maximum": 23431.38, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23431.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 2", "code_information": [ { "code": "4702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4928.4, "maximum": 5273.39, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5273.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 143379.99, "maximum": 143379.99, "payers_information": [ { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 143379.99 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12904, "minimum": 10022.92, "maximum": 23382.7003, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12904.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13033.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20981.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19620.22 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16775.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12904.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23382.7, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18840.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 18143.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13678.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12904.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12904.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20646.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10777.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12904.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20981.92 } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 4", "code_information": [ { "code": "3844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15409.61, "maximum": 16488.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16488.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Compl Oph Exam General Anes", "code_information": [ { "code": "92018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8400, "discounted_cash": 3042, "minimum": 68.68, "maximum": 8400, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4564.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3073.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4008.51, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3888.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 4260, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4442.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4278.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3225.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3042.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4008.51, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 2", "code_information": [ { "code": "2032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4785.29, "maximum": 5120.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5120.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 80847, "minimum": 48600, "maximum": 146495.8331, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 80847.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 81656.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 139921.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 131306.26 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 105101.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 80847.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 146495.83, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 118037.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 113671.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 85698.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 80847.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 80847.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 129356.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70655.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 80847.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 139921.85 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 1", "code_information": [ { "code": "0951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7198.08, "maximum": 7701.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7701.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6991, "minimum": 6991.28, "maximum": 20642.92, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7061.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11355.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11290.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9088.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12668.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10207.27, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9829.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7410.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11186.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7168.99 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6991.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11355.37 } ] } ] }, { "description": "CHEST PAIN - SOI : 3", "code_information": [ { "code": "2033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6017.13, "maximum": 6438.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6438.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29768.67, "maximum": 31852.48, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31852.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 4", "code_information": [ { "code": "0954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19181.45, "maximum": 20524.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20524.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION WITH CC", "code_information": [ { "code": "089", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10904, "minimum": 10904.7, "maximum": 19759.3345, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10904.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11013.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17702.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18605.71 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14176.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10904.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19759.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15920.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15332.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11558.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10904.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10904.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17447.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18142.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17702.62 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30086, "minimum": 13500, "maximum": 54516.6655, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30086.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30387.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 50503.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47782 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 39112.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 30086.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 54516.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 43926.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 42301.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31891.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30086.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30086.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48138.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33873.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30086.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50503.9 } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 1", "code_information": [ { "code": "6611", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6078.61, "maximum": 6504.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6504.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 2", "code_information": [ { "code": "0572", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6917.15, "maximum": 7401.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7401.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 64640, "minimum": 39600, "maximum": 119383, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 64640.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 65286.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 112749.55 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98541.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 84032.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 64640.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 117128.6, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 94375.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 90884.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68518.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 64640.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 64640.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 103424.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 119383 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 64640.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112749.55 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7742", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3481.37, "maximum": 3725.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 1", "code_information": [ { "code": "3461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5540.08, "maximum": 5927.89, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5927.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20482, "minimum": 19800, "maximum": 37113.8008, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20482.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20687.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35197.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33430.09 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26626.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20482.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37113.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29904.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28798.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21711.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20482.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20482.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32771.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28219.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20482.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35197.18 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 56988.86, "maximum": 60978.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60978.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11427, "minimum": 9867.16, "maximum": 20706.6662, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16067.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12113.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11427.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11427.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18284.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14989.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11427.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11427.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11541.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19405.02 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14855.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11427.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20706.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16684.18, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16265, "minimum": 12600, "maximum": 29472.9229, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16265.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16428.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27451.36 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24425.76 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21145.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16265.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29472.92, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23747.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22869.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17241.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16265.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16265.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26024.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22009.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16265.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27451.36 } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 1", "code_information": [ { "code": "0451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6539.76, "maximum": 6997.54, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6997.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 98963.49, "maximum": 98963.49, "payers_information": [ { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98963.49 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8401, "minimum": 8401.34, "maximum": 22784.62, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8485.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12321.33 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13321.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10921.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15223.23, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12265.96, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11812.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8905.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13442.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9637.78 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8401.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12321.33 } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 1", "code_information": [ { "code": "4701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3852.4, "maximum": 4122.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4122.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 4", "code_information": [ { "code": "0454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16939.34, "maximum": 18125.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18125.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 74519.93, "maximum": 74519.93, "payers_information": [ { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74519.93 } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 1", "code_information": [ { "code": "3841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4735.47, "maximum": 5066.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 3", "code_information": [ { "code": "4703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8182.91, "maximum": 8755.71, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 2", "code_information": [ { "code": "1792", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33373.01, "maximum": 35709.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35709.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9985, "minimum": 8123.12, "maximum": 18094.5958, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10085.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16774.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16727.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12981.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18094.6, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14579.53, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14040.29, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10585.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15977.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9850.07 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9985.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16774.64 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1653", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 46931.69, "maximum": 50216.91, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50216.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 4", "code_information": [ { "code": "4704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14561.53, "maximum": 15580.84, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15580.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12784, "minimum": 12784.16, "maximum": 23164.8979, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12784.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23164.9, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18664.87, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17974.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13551.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12784.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12784.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20454.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19270.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22033.74 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12784.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12784.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12912.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22033.74 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22056.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16619.41, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17890, "minimum": 11827.14, "maximum": 32416.9156, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17890.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18069, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30111.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29524.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23257.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 17890.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32416.92, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26119.59, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25153.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18963.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17890.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17890.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28624.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17006 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17890.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30111.46 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1654", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 63659, "maximum": 68115.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68115.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4604.01, "maximum": 4926.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4926.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7183, "minimum": 6950.74, "maximum": 22587.56, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7254.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10891.38 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10924.93 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9337.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13015.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10487.24, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10099.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7614.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11492.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6950.74 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7183.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10891.38 } ] } ] }, { "description": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8277, "minimum": 8277.31, "maximum": 15125.33, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8360.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14155.82 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15125.33 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10760.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14998.49, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12084.87, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11637.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8773.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13243.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14862.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8277.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14155.82 } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 73361, "minimum": 50850, "maximum": 132930.6937, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 73361.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 74094.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 129065.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 126199.76 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 95369.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 73361.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 132930.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 107107.51, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 103146, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 77762.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 73361.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 73361.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 117378.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 93592.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 73361.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 129065.15 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5528.42, "maximum": 5915.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5915.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 2", "code_information": [ { "code": "1142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4606.13, "maximum": 4928.56, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0571", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4449.24, "maximum": 4760.69, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4760.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 58262, "minimum": 34200, "maximum": 105572.2117, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 58262.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 58845.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 100867.44 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96250.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 75741.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 58262.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 105572.21, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 85063.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 81917.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61758.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 58262.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 58262.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 93220.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80869.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 58262.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100867.44 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10991, "minimum": 10769.6, "maximum": 19916.6524, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10991.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11101.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18543.08 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17830.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14288.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10991.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19916.65, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16047.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15454.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11650.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10991.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10991.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17586.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10769.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10991.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18543.08 } ] } ] }, { "description": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9400, "minimum": 5471.86, "maximum": 18000, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9494.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15093.71 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14667.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12220.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17033.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13724.31, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13216.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9964.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15040.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5471.86 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9400.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15093.71 } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 4", "code_information": [ { "code": "0574", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16634.03, "maximum": 17798.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17798.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55046.75, "maximum": 58900.02, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58900.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6548, "minimum": 5971.58, "maximum": 11866.0813, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6614.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10686.63 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10384.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8513.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11866.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9560.97, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9207.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6941.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10477.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5971.58 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10686.63 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 2", "code_information": [ { "code": "3462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7614.7, "maximum": 8147.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Corrj halux rigdus wo implt", "code_information": [ { "code": "28289", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10993.13, "discounted_cash": 4187, "minimum": 458.19, "maximum": 10993.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10993.1, "discounted_cash": 4187, "minimum": 458.19, "maximum": 10993.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21534, "minimum": 12627.18, "maximum": 39020.5684, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21534.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21749.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36546.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34878.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27994.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 21534.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39020.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31440.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 30277.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22826.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21534.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21534.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34455.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24310.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21534.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36546.22 } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 2", "code_information": [ { "code": "3842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6140.1, "maximum": 6569.91, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6569.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10500, "minimum": 10500.2, "maximum": 19026.3805, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10500.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10605.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17664.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16681.88 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13650.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10500.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19026.38, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15330.31, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14763.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11130.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10500.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10500.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16800.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12037.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10500.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17664.64 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1651", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 35209.1, "maximum": 37673.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37673.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10257, "minimum": 10257.88, "maximum": 18587.2786, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10257.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10360.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17212.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16604.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13335.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10257.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18587.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14976.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14422.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10873.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10257.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10257.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16412.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11175.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10257.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17212.21 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19200, "minimum": 19200.97, "maximum": 34792.1576, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19200.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19393.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32348.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31001.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24961.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19200.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34792.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28033.42, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26996.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20353.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19200.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19200.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30721.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19200.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23626.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19201, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32348.85 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1652", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38566.44, "maximum": 41266.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41266.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33747.22, "maximum": 36109.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36109.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 3", "code_information": [ { "code": "0953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10607.36, "maximum": 11349.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11349.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52539, "minimum": 36450, "maximum": 95201.719, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 73870.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55691.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52539.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52539.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 84063.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 76764.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87847.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 52539.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 52539.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53065, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 87847.65 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84103.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 68301.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 52539.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 95201.72, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 76707.79, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR", "code_information": [ { "code": "023", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55092, "minimum": 32850, "maximum": 99827.7368, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 55092.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 55643.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 94203.16 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91722.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 71620.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 55092.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 99827.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 80435.15, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 77460.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58398.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 55092.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55092.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88148.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 75488.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 55092.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94203.16 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40386, "minimum": 26100, "maximum": 73179.7582, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 40386.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40790.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 67899.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65387.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 52502.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 40386.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73179.76, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 58963.82, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 56782.97, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42809.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40386.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40386.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64617.89, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 58291.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40386.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67899.39 } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 2", "code_information": [ { "code": "0452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8072.66, "maximum": 8637.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8637.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 2", "code_information": [ { "code": "6612", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7714.35, "maximum": 8254.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8254.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 3", "code_information": [ { "code": "4203", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7786.43, "maximum": 8331.48, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8331.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39961.53, "maximum": 42758.84, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42758.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 4", "code_information": [ { "code": "6614", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19298.06, "maximum": 20648.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20648.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 2", "code_information": [ { "code": "2402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7210.8, "maximum": 7715.56, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7715.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15729, "minimum": 15729.25, "maximum": 28501.401, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15729.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15886.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25521.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24480.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20448.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15729.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28501.4, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22964.71, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22115.33, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16673.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15729.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15729.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25166.8, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17946.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25521.1 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8061, "minimum": 7071.2, "maximum": 14607.8004, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8142.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12372.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12250.1 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10480.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14607.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11770.08, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11334.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8545.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12898.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7071.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12372.51 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43800, "minimum": 29250, "maximum": 79366.7959, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 43800.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 44238.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 73847.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71452.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 56940.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 43800.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 79366.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 63948.96, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 61583.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46428.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43800.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43800.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 70081.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50954.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43800.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73847.05 } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13320, "minimum": 13320.3, "maximum": 24817.32, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13320.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13453.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23293.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24817.32 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17316.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13320.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24136.42, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19447.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 18728.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14119.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13320.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13320.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21312.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18675.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13320.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23293.61 } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 3", "code_information": [ { "code": "5173", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12821.91, "maximum": 13719.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13719.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22594.97, "maximum": 24176.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24176.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17564.8, "maximum": 18794.34, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18794.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 3", "code_information": [ { "code": "3463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11432.12, "maximum": 12232.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12232.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 4", "code_information": [ { "code": "5174", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21946.19, "maximum": 23482.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23482.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC", "code_information": [ { "code": "024", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 37744, "minimum": 17550, "maximum": 68392.9796, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 37744.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 38121.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 62774.04 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61303.87 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 49067.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 37744.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 68392.98, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55106.93, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 53068.72, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40009.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 37744.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 37744.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 60391.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46491.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37744.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62774.04 } ] } ] }, { "description": "CYSTOSCOPY AND TREATMENT", "code_information": [ { "code": "52310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7000, "discounted_cash": 2675, "minimum": 422.95, "maximum": 7000, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 444.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 452.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 7000, "discounted_cash": 2675, "minimum": 422.95, "maximum": 7000, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 444.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 452.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 422.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24099, "minimum": 13610.12, "maximum": 43669.055, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 24099.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24340.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41724.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40340.69 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31329.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 24099.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43669.06, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 35185.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 33884.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25545.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24099.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24099.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38559.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28908.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24099.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41724.42 } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12532.5, "maximum": 13409.78, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13409.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 3", "code_information": [ { "code": "3843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8929.22, "maximum": 9554.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9554.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 3", "code_information": [ { "code": "2823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9386.13, "maximum": 10043.16, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10043.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19972, "minimum": 13422.5, "maximum": 36190.6774, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19972.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20172.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32264.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30457.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25964.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19972.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36190.68, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29160.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28081.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21171.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19972.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19972.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31956.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18180.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32264.64 } ] } ] }, { "description": "Dbrdmt Subq Tis 1St 20Sqcm/<", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 520, "minimum": 109.0635, "maximum": 10500, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 780.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 525.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 728.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 759.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 731.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 159.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 551.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56411, "minimum": 36450, "maximum": 102218.5259, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 56411.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56976.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 97160.48 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 95149.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 73335.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 56411.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 102218.53, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 82361.51, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 79315.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 59796.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 56411.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56411.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 90259.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56411.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 72124.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56412, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 97160.48 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8449, "minimum": 8449.04, "maximum": 15309.6605, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14203.71 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8533.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14203.71 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13837.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10983.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15309.66, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12335.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11879.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8955.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13518.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9089.16 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8449.04, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5370.18, "maximum": 13041.2534, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13041.25 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12897.31 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10455.9 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13041.25 } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1662", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33063.46, "maximum": 35377.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35377.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 1", "code_information": [ { "code": "7521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2817.75, "maximum": 3014.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3014.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 1", "code_information": [ { "code": "1791", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28107.49, "maximum": 30075.01, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30075.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 3", "code_information": [ { "code": "1793", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 40597.59, "maximum": 43439.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43439.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41708, "minimum": 20700, "maximum": 75575.7476, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 41708.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 42125.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 70331.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66986.39 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 54221.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 41708.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 75575.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 60894.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 58642.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44211.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 41708.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41708.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 66733.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63079.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 41708.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70331.62 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 4", "code_information": [ { "code": "7524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33313.64, "maximum": 35645.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35645.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 4", "code_information": [ { "code": "1794", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54992.69, "maximum": 58842.18, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58842.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 3", "code_information": [ { "code": "0423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10008.4, "maximum": 10708.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10708.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30485, "minimum": 10350, "maximum": 58851.32, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30485.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30790.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52757.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48032.8 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 39630.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 30485.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55239.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44508.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 42862.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32314.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30485.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30485.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48776.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47548.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30485.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52757.8 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10864, "minimum": 10477.4, "maximum": 19686.7458, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10864.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10973.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17907.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17584.74 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14124.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10864.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19686.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15862.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15275.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10864.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10864.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17383.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10477.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10864.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17907.37 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 2", "code_information": [ { "code": "0422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7420.7, "maximum": 7940.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7940.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31051, "minimum": 12150, "maximum": 56266.1153, "payers_information": [ { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37889.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47259.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31051.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31362.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 47259.27 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42785.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 40367.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 31051.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56266.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45335.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 43659.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32915.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31051.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31051.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31051.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49683.1, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 1", "code_information": [ { "code": "2441", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4359.13, "maximum": 4664.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4664.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22586, "minimum": 22586.8, "maximum": 41347.9396, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22586.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22812.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41347.94 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38735.61 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 29362.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 22586.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40927.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32976.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 31757.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23942.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22586.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22586.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36138.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28857.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22586.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41347.94 } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 3", "code_information": [ { "code": "2443", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8730.98, "maximum": 9342.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 1", "code_information": [ { "code": "1141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3289.49, "maximum": 3519.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3519.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 4", "code_information": [ { "code": "1144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15815.63, "maximum": 16922.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16922.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 4", "code_information": [ { "code": "4204", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14323.01, "maximum": 15325.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15325.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "027", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24492, "minimum": 7200, "maximum": 44381.2798, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 24492.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24737.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 40748.55 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39365.02 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31840.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 24492.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44381.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 35759.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 34437.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25962.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24492.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24492.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39188.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24492.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33817.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24493, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40748.55 } ] } ] }, { "description": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6350, "minimum": 5469.48, "maximum": 15760.08, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6413.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10346.48 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10072.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8255.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11506.51, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9271.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 8928.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6731.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10160.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5469.48 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6350.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10346.48 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22650.1, "maximum": 24235.61, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24235.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 3", "code_information": [ { "code": "0453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10803.48, "maximum": 11559.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11559.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 2", "code_information": [ { "code": "4202", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5392.73, "maximum": 5770.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 3", "code_information": [ { "code": "2403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10169.54, "maximum": 10881.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10881.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7099.49, "maximum": 7596.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7596.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12554, "minimum": 12554.2, "maximum": 22748.2648, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12554.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12679.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20554.26 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19995.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16320.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12554.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22748.26, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18329.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17651.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13307.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12554.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12554.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20086.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14506.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12554.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20554.26 } ] } ] }, { "description": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8973, "minimum": 7330.16, "maximum": 16260.4531, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9063.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15144.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14552.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11665.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16260.45, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13101.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12617.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9512.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14358.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7553.03 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8973.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15144.89 } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18877.2, "maximum": 20198.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20198.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20624, "minimum": 8868.88, "maximum": 37880.3994, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20624.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20830.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37880.4 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34156.59 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26811.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20624.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37371.38, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30111.59, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28997.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21861.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20624.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20624.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32999.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17000 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20624.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37880.4 } ] } ] }, { "description": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14130, "minimum": 10575.16, "maximum": 25604.0855, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14130.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14271.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24046.57 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23450.09 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18369.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14130.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25604.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20630.22, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19867.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14978.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14130.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14130.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22608.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12754.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24046.57 } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 1", "code_information": [ { "code": "5171", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6167.66, "maximum": 6599.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6599.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11275, "minimum": 5188.01, "maximum": 20497.78, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11275.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11388.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16921.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16761.16 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14658.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11275.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20431.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16462.71, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15853.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11952.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11275.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11275.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18041.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5188.01 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11275.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16921.6 } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 1", "code_information": [ { "code": "1101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6412.54, "maximum": 6861.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6861.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 4", "code_information": [ { "code": "2404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15872.88, "maximum": 16983.98, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16983.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 1", "code_information": [ { "code": "7591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6174.02, "maximum": 6606.2, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6606.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9241, "minimum": 9241.84, "maximum": 16746.2141, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9334.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14580.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14423.11 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12014.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16746.21, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13493.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12994.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9796.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14786.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10594.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14580.18 } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 1", "code_information": [ { "code": "2841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5267.64, "maximum": 5636.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5636.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7481.2, "maximum": 20276.8539, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20276.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17696.38 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16257 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20276.85 } ] } ] }, { "description": "EATING DISORDERS - SOI : 2", "code_information": [ { "code": "7592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8406.59, "maximum": 8995.05, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8995.05, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 2", "code_information": [ { "code": "2842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7392.08, "maximum": 7909.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7909.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 1", "code_information": [ { "code": "0421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5906.88, "maximum": 6320.36, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6320.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES", "code_information": [ { "code": "003", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 202918, "minimum": 108450, "maximum": 367688.7206, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 202918.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 204948.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 353880.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 344968.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 263794.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 202918.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 367688.72, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 296261.33, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 285303.72, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 215094.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 202918.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 202918.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 324669.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 202918.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 308352 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 202919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 353880.64 } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 3", "code_information": [ { "code": "2843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9985.08, "maximum": 10684.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10684.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 4", "code_information": [ { "code": "2844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17059.13, "maximum": 18253.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18253.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 4", "code_information": [ { "code": "0424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18420.3, "maximum": 19709.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19709.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3243", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19651.07, "maximum": 21026.64, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21026.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9632, "minimum": 9632.99, "maximum": 17454.9779, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9729.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15953.99 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15395.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12522.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17454.98, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14064.17, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13543.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10210.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15412.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11122.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15953.99 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 4", "code_information": [ { "code": "2824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 20005.15, "maximum": 21405.51, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21405.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9103, "minimum": 9103.5, "maximum": 29783.2, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14565.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9788.05 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15531.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9194.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15531.28 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15185.2 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11834.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16495.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13291.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12799.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9649.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9103.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25927.93, "maximum": 27742.89, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27742.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "441", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17545, "minimum": 17545.7, "maximum": 31792.8446, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17545.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17721.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31214.47 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29580.8 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22809.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 17545.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31792.84, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25616.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 24669.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18598.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17545.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17545.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28073.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21569 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17545.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31214.47 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15976, "minimum": 15976.3, "maximum": 28949.1281, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15976.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16136.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27471.17 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27001.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20769.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15976.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28949.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23325.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22462.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16934.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15976.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15976.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25562.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19471.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27471.17 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16802, "minimum": 16802.5, "maximum": 52885.24, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16802.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16970.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27038.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27619.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21843.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16802.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30446.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24531.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23624.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17810.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16802.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16802.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26884.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19276.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16802.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27038.56 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16128, "minimum": 12095, "maximum": 29223.9904, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16128.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16289.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27365.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26618.19 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20966.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16128.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29223.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23546.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22676.01, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17095.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16128.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16128.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25804.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16128.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17682.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16128, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27365.5 } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "443", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7099, "minimum": 7099.08, "maximum": 12863.533, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7170.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11603.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11564.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9228.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12863.53, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10364.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9981.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7525.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11358.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7163.03 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11603.05 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 2", "code_information": [ { "code": "7522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3671.13, "maximum": 3928.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3928.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 3", "code_information": [ { "code": "1143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6926.69, "maximum": 7411.56, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7411.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7753, "minimum": 6142.13, "maximum": 55476.52, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7831.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12857.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12311.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10079.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14049.43, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11320.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10901.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8218.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12405.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6142.13 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7753.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12857.97 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 2", "code_information": [ { "code": "2822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5998.05, "maximum": 6417.91, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6417.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16364, "minimum": 15970.7, "maximum": 29652.7096, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16364.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16528.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27812.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26425.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21274.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16364.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29652.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23892.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23008.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17346.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16364.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16364.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26183.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15970.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16364.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27812.97 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6352, "minimum": 6352.08, "maximum": 11509.969, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6415.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10156.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9960.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8257.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11509.97, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9274.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 8931.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6733.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10163.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6831.48 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6352.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10156.59 } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 2", "code_information": [ { "code": "2442", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5831.61, "maximum": 6239.82, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6239.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 3", "code_information": [ { "code": "7523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7618.94, "maximum": 8152.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8152.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19182, "minimum": 12296, "maximum": 34759.3061, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19182.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19374.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30611.77 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30344.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24937.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19182.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34759.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28006.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26971.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20333.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19182.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19182.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30692.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14620.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19182.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30611.77 } ] } ] }, { "description": "DIABETES - SOI : 1", "code_information": [ { "code": "4201", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4059.12, "maximum": 4343.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4343.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 4", "code_information": [ { "code": "2444", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15668.28, "maximum": 16765.06, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16765.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3041", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21066.31, "maximum": 22540.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22540.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC ARMELBOW LES SC 3 CM>", "code_information": [ { "code": "24071", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2953.12, "discounted_cash": 3717, "minimum": 334.7, "maximum": 2953.12, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 351.44 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 358.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 334.7 } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 32600.2, "maximum": 34882.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34882.21, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Foot/Toe Tum Sc 1.5 Cm/>", "code_information": [ { "code": "28039", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16800, "discounted_cash": 3717, "minimum": 405.81, "maximum": 16800, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 426.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 434.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3042", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28158.38, "maximum": 30129.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30129.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36947.67, "maximum": 39534.01, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39534.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc hand tum deep 1.5 cm>", "code_information": [ { "code": "26113", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13125, "discounted_cash": 2113, "minimum": 451.97, "maximum": 13125, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13125, "discounted_cash": 2113, "minimum": 451.97, "maximum": 13125, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 451.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3043", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38877.05, "maximum": 41598.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41598.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 74045.86, "maximum": 79229.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 79229.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 1", "code_information": [ { "code": "2401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5584.61, "maximum": 5975.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Leg/Ankle Tum Deep <5 Cm", "code_information": [ { "code": "27619", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18375, "discounted_cash": 3717, "minimum": 529.22, "maximum": 18375, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 566.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 555.68 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 3", "code_information": [ { "code": "7703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5481.78, "maximum": 5865.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5865.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11963, "minimum": 11963.69, "maximum": 21678.2063, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11963.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12083.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20288.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19388.84 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15552.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11963.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21678.21, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17466.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16820.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12681.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11963.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11963.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19141.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13686.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20288.41 } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 3", "code_information": [ { "code": "8413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 52320.18, "maximum": 55982.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55982.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 1", "code_information": [ { "code": "7701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2155.18, "maximum": 2306.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2306.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 4", "code_information": [ { "code": "1104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17487.41, "maximum": 18711.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18711.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20827, "minimum": 20827.59, "maximum": 37739.5931, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20827.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21035.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34863.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33962.42 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27075.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 20827.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37739.59, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30408.28, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 29283.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22077.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20827.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20827.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33324.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25913.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20827.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34863.64 } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15548.49, "maximum": 16636.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16636.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 4", "code_information": [ { "code": "7704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10998.54, "maximum": 11768.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11768.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3241", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12305.64, "maximum": 13167.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 2", "code_information": [ { "code": "5172", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8522.14, "maximum": 9118.69, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9118.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29241.8, "maximum": 31288.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31288.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 3", "code_information": [ { "code": "1103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10282.97, "maximum": 11002.78, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11002.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3244", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29312.83, "maximum": 31364.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31364.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT", "code_information": [ { "code": "927", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 204114, "minimum": 84637.86, "maximum": 426491.32, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 204114.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 369854.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 298006.62, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 286984.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 216360.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 204114.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 204114.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 326582.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 204114.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 314051 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 391713.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 204114, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 204114.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 206155.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 391713.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 426491.32 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 265348.36, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3242", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13814.16, "maximum": 14781.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14781.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12960.78, "maximum": 13868.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13868.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 1", "code_information": [ { "code": "2821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4490.58, "maximum": 4804.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4804.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23878, "minimum": 18450, "maximum": 43267.987, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23878.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24117.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 40426.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40224.19 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31042.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 23878.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43267.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34862.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 33573.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25311.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23878.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23878.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38205.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28349.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23878.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40426.56 } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12205.99, "maximum": 13060.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13060.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18607.94, "maximum": 19910.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19910.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8316, "minimum": 7988.35, "maximum": 15069.3712, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8399.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13165.09 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12968.5 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10811.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15069.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12141.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11692.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8815.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13306.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7988.35 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8316.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13165.09 } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 3", "code_information": [ { "code": "7923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22449.74, "maximum": 24021.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24021.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 58890, "minimum": 11700, "maximum": 106709.7128, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 58890.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 59479.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98920.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101063.69 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 76557.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 58890.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 106709.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 85980.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 82800.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62424.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 58890.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 58890.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 94224.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50097.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 58890.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98920.66 } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3044", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54426.59, "maximum": 58236.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58236.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 3", "code_information": [ { "code": "8433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11688.66, "maximum": 12506.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12506.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10202, "minimum": 9065.94, "maximum": 18487.0206, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10202.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10304.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17063.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17178.61 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13263.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10202.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18487.02, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14895.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14344.79, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10814.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10202.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10202.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16324.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9790.43 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17063.6 } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 49432.46, "maximum": 52892.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52892.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 4", "code_information": [ { "code": "8434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16967.96, "maximum": 18155.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18155.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 1", "code_information": [ { "code": "1781", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39720.89, "maximum": 42501.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42501.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 2", "code_information": [ { "code": "7702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3378.54, "maximum": 3615.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3615.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 2", "code_information": [ { "code": "1782", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 43293.42, "maximum": 46323.96, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46323.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7594, "minimum": 7594.23, "maximum": 13949.96, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7670.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12342.79 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12049.46 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9872.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13760.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11087.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10677.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8049.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12150.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9159.52 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12342.79 } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 1", "code_information": [ { "code": "0091", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 48887.57, "maximum": 52309.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52309.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8028, "minimum": 8028.31, "maximum": 14547.2977, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13221.24 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14395.6 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10436.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14547.3, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11721.33, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11287.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8510.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12845.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10600.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8028.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13221.24 } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 3", "code_information": [ { "code": "0823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8121.43, "maximum": 8689.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8689.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7861, "minimum": 7691.38, "maximum": 14244.7843, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12884.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12711.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10219.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14244.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11477.59, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11053.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8333.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12578.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7691.38 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7861.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12884.39 } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 2", "code_information": [ { "code": "1102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6936.23, "maximum": 7421.77, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7421.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 4", "code_information": [ { "code": "0824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14031.48, "maximum": 15013.68, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15013.68, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 3", "code_information": [ { "code": "7593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13046.65, "maximum": 13959.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13959.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC SHOULDER TUM DEEP < 5 CM", "code_information": [ { "code": "23076", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13518.75, "discounted_cash": 3717, "minimum": 701.18, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 750.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13518.8, "discounted_cash": 3717, "minimum": 701.18, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 736.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 750.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 4", "code_information": [ { "code": "7594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 23951.9, "maximum": 25628.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25628.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 1", "code_information": [ { "code": "5311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4150.29, "maximum": 4440.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4440.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC ABD LES SC 3 CM>", "code_information": [ { "code": "22903", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2953.12, "discounted_cash": 3717, "minimum": 362.25, "maximum": 2953.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 380.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 387.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 1", "code_information": [ { "code": "8411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15021.62, "maximum": 16073.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16073.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45843, "minimum": 4826.64, "maximum": 83067.9509, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 45843.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46301.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 77684.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78963.04 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 59596.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 45843.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83067.95, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 66931.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 64455.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48593.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 45843.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45843.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 73349.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4826.64 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45843.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77684.46 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 2", "code_information": [ { "code": "5312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5424.53, "maximum": 5804.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5804.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC FACE TUM DEEP < 2 CM", "code_information": [ { "code": "21013", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11812.52, "discounted_cash": 2113, "minimum": 414.37, "maximum": 11812.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 435.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 11812.5, "discounted_cash": 2113, "minimum": 414.37, "maximum": 11812.52, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 435.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 4", "code_information": [ { "code": "8414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 173017.86, "maximum": 185129.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 185129.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 3", "code_information": [ { "code": "5303", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9625.71, "maximum": 10299.51, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10299.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc foottoe tum sc < 1.5 cm", "code_information": [ { "code": "28043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 2113, "minimum": 433.1, "maximum": 10500, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 463.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 2113, "minimum": 433.1, "maximum": 10500, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 463.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18876.14, "maximum": 20197.47, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20197.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 4", "code_information": [ { "code": "5304", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14427.96, "maximum": 15437.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15437.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc thighknee les sc < 3 cm", "code_information": [ { "code": "27327", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13518.8, "discounted_cash": 2113, "minimum": 551.66, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13518.75, "discounted_cash": 2113, "minimum": 551.66, "maximum": 13518.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 3", "code_information": [ { "code": "9503", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 26055.14, "maximum": 27879, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27879, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 1", "code_information": [ { "code": "5141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7944.39, "maximum": 8500.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8500.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16898.4, "discounted_cash": 2113, "minimum": 277.15, "maximum": 16898.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 291.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 16898.44, "discounted_cash": 2113, "minimum": 277.15, "maximum": 16898.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 291.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 2", "code_information": [ { "code": "8432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5940.8, "maximum": 6356.66, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6356.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EPISTAXIS WITH MCC", "code_information": [ { "code": "150", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13126, "minimum": 8710.76, "maximum": 23785.4898, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13126.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13257.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22823.02 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21268.99 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17064.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13126.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23785.49, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19164.91, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 18456.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13914.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13126.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13126.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21002.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18297.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13126.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22823.02 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 4", "code_information": [ { "code": "5144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28211.38, "maximum": 30186.18, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30186.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Tr-Ext B9+Marg 3.1-4 Cm", "code_information": [ { "code": "11404", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15750, "discounted_cash": 2113, "minimum": 127.1, "maximum": 15750, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 133.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 3", "code_information": [ { "code": "1783", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 53704.67, "maximum": 57464, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57464, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EPISTAXIS WITHOUT MCC", "code_information": [ { "code": "151", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7426, "minimum": 5939.37, "maximum": 18449.3, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7500.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12516.17 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12470.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9654.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13456.49, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10842.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10441.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7871.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11882.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5939.37 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7426.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12516.17 } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 2", "code_information": [ { "code": "8412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27312.42, "maximum": 29224.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29224.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 4", "code_information": [ { "code": "0094", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 194638.6, "maximum": 208263.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 208263.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 2", "code_information": [ { "code": "9502", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16736.86, "maximum": 17908.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17908.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "038", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15903, "minimum": 8550, "maximum": 28817.7581, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15903.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16062.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26605.94 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25886.84 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20674.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15903.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28817.76, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23219.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 22360.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16858.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15903.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15903.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25446.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23897 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15903.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26605.94 } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12523, "minimum": 12352.2, "maximum": 22692.9625, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12523.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12648.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21209.79 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20641.19 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16280.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12523.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22692.96, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18284.62, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17608.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13275.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12523.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12523.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20037.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12352.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12523.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21209.79 } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 4", "code_information": [ { "code": "9504", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 44744.7, "maximum": 47876.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47876.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 2", "code_information": [ { "code": "0822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5772.24, "maximum": 6176.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6176.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC ABD LES SC < 3 CM", "code_information": [ { "code": "22902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2953.12, "discounted_cash": 2113, "minimum": 357.41, "maximum": 2953.12, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 382.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 357.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "150.00% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC", "code_information": [ { "code": "981", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45184, "minimum": 29010.3, "maximum": 81875.1475, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 45184.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45636.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 78496.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76701.03 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 58740.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 45184.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 81875.15, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 65970.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 63530.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47896.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 45184.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45184.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 72295.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45184.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 66761.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45185, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78496.85 } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 1", "code_information": [ { "code": "0921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11178.75, "maximum": 11961.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11961.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC BACK LES SC 3 CM>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2953.12, "discounted_cash": 2113, "minimum": 386.08, "maximum": 2953.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2953.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 413.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 1", "code_information": [ { "code": "7921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12017.29, "maximum": 12858.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12858.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 2", "code_information": [ { "code": "0922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14154.46, "maximum": 15145.27, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15145.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Shoulder Les Sc < 3 Cm", "code_information": [ { "code": "23075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 2113, "minimum": 173.56, "maximum": 10500, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 182.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 4", "code_information": [ { "code": "7924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38747.72, "maximum": 41460.06, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41460.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 3", "code_information": [ { "code": "5313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8474.44, "maximum": 9067.65, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9067.65, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Skn Hdrdnt Ax Smpl/Ntrm", "code_information": [ { "code": "11450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15375, "discounted_cash": 3717, "minimum": 168.76, "maximum": 15375, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 180.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 3", "code_information": [ { "code": "3143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15322.69, "maximum": 16395.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16395.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 1", "code_information": [ { "code": "8431", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4519.21, "maximum": 4835.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4835.55, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 3", "code_information": [ { "code": "5143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15285.58, "maximum": 16355.57, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16355.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg 2.1-3cm", "code_information": [ { "code": "11403", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8200, "discounted_cash": 906, "minimum": 116.42, "maximum": 8200, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 8200, "discounted_cash": 906, "minimum": 116.42, "maximum": 8200, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 4", "code_information": [ { "code": "3144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25759.37, "maximum": 27562.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27562.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 4", "code_information": [ { "code": "1784", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66228.69, "maximum": 70864.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70864.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54718.12, "maximum": 58548.39, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58548.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18256, "minimum": 18000, "maximum": 33080.7418, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18256.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18439.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27944.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23733.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 18256.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33080.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26654.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25668.61, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19351.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18256.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18256.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29210.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22700.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18256.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.73 } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 3", "code_information": [ { "code": "0093", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 110110.47, "maximum": 117818.2, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 117818.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 4", "code_information": [ { "code": "7224", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8918.62, "maximum": 9542.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9542.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT", "code_information": [ { "code": "933", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 37575, "minimum": 11700, "maximum": 71446.1882, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 37575.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 37951.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 71446.19 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49058.63 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 48848.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 37575.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 68087.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 54860.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 52831.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39830.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 37575.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 37575.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 60120.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 57281.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37575.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71446.19 } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 3", "code_information": [ { "code": "3403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7442.96, "maximum": 7963.97, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7963.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRAOCULAR PROCEDURES EXCEPT ORBIT", "code_information": [ { "code": "115", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15067, "minimum": 13726.94, "maximum": 27770.8, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15067.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15217.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25280.02 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25312.44 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19587.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15067.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27301.68, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21998.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21184.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15971.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15067.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15067.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24107.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27770.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15067.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25280.02 } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 1", "code_information": [ { "code": "9501", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12415.89, "maximum": 13285, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13285, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 4", "code_information": [ { "code": "3404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11119.39, "maximum": 11897.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11897.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE", "code_information": [ { "code": "790", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57126, "minimum": 8759.99, "maximum": 103513.3267, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 57126.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 57697.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98161.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 97083.34 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 74264.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 57126.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 103513.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83404.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 80319.94, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60554.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57126.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57126.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91402.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8759.99 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 57126.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98161.11 } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 2", "code_information": [ { "code": "3142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10597.82, "maximum": 11339.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11339.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "983", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16775, "minimum": 9000, "maximum": 40455.12, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16775.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16943.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27545.48 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26458 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21808.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 16775.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30397.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24492.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23586.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17782.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16775.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16775.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26841.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15146.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27545.48 } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 1", "code_information": [ { "code": "3411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 4728.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 1", "code_information": [ { "code": "0821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 4728.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 1", "code_information": [ { "code": "3401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4081.39, "maximum": 4367.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4367.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 2", "code_information": [ { "code": "7922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15308.9, "maximum": 16380.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16380.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITHOUT MCC", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8128, "minimum": 7600.74, "maximum": 14728.8058, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8209.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13389.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12735.5 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10567.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14728.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11867.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11428.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8616.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13005.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7600.74 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8128.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13389.66 } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 3", "code_information": [ { "code": "0923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21195.64, "maximum": 22679.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22679.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 2", "code_information": [ { "code": "3402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5213.57, "maximum": 5578.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5578.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 2", "code_information": [ { "code": "0092", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 60423.58, "maximum": 64653.23, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 64653.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FULL TERM NEONATE WITH MAJOR PROBLEMS", "code_information": [ { "code": "793", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40203, "minimum": 14311.5, "maximum": 72847.8541, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 40203.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40605.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 68863.7 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68107.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 52263.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 40203.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 72847.85, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 58696.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 56525.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42615.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40203.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40203.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64324.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40203.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 55211.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40203, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68863.7 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 4", "code_information": [ { "code": "5314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15745.67, "maximum": 16847.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16847.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 2", "code_information": [ { "code": "3412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5488.14, "maximum": 5872.31, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5872.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "037", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31831, "minimum": 22050, "maximum": 57678.4606, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31831.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32149.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 54835.02 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54618.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 41380.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 31831.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57678.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46473.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 44754.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33741.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31831.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31831.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50930.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54350.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31831.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54835.02 } ] } ] }, { "description": "FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CCMCC", "code_information": [ { "code": "929", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31151, "minimum": 20779.5, "maximum": 56445.9019, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31151.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31462.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52515.07 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52027.71 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 40496.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 31151.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56445.9, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45480.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 43798.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33020.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31151.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31151.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49841.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20779.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31151.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52515.07 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 1", "code_information": [ { "code": "5301", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4830.88, "maximum": 5169.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5169.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC", "code_information": [ { "code": "562", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14016, "minimum": 10566.9, "maximum": 25398.3691, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19707.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14857.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14016.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14016.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22426.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15519.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24165.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14016.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14156.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24165.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24605.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18221.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14016.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25398.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20464.47, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11638, "minimum": 5400, "maximum": 21088.7083, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11638.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11754.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18794.07 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18461.71 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15129.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 11638.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21088.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16992.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16363.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12336.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11638.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11638.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18621.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19526 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18794.07 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 2", "code_information": [ { "code": "5302", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6392.4, "maximum": 6839.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6839.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 4", "code_information": [ { "code": "3424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15077.8, "maximum": 16133.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16133.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 4", "code_information": [ { "code": "0924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39182.36, "maximum": 41925.13, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41925.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITH MCC", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12654, "minimum": 9529.68, "maximum": 22929.7909, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12654.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12780.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21959.44 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20980.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16450.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 12654.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22929.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18475.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17792.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13413.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12654.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12654.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20247.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17605.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12654.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21959.44 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES", "code_information": [ { "code": "748", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13659, "minimum": 6300, "maximum": 30297.68, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13795.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22494.43 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22731.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17756.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24750.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19942.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19204.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14478.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21854.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22997.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13659, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22494.43 } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 2", "code_information": [ { "code": "2322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11514.81, "maximum": 12320.85, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12320.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS", "code_information": [ { "code": "864", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8892, "minimum": 7532.75, "maximum": 17679.94, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8981.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14827.86 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14283.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11560.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16113.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12983.28, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12503.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9426.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14228.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7532.75 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14827.86 } ] } ] }, { "description": "FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CCMCC", "code_information": [ { "code": "928", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 68853, "minimum": 38005.44, "maximum": 124762.5601, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 68853.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 69542.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 110282.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111962.73 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 89509.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 68853.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 124762.56, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 100526.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 96808.04, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 72984.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 68853.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 68853.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 110165.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 41031.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 68853.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110282.64 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 2", "code_information": [ { "code": "5142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11619.76, "maximum": 12433.14, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 3", "code_information": [ { "code": "2323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17865.87, "maximum": 19116.48, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19116.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 1", "code_information": [ { "code": "7221", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3387.02, "maximum": 3624.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3624.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 1", "code_information": [ { "code": "2321", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9808.05, "maximum": 10494.61, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10494.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 2", "code_information": [ { "code": "7222", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4749.25, "maximum": 5081.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5081.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITHOUT CCMCC", "code_information": [ { "code": "390", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5613, "minimum": 5104.52, "maximum": 10350, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5669.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9035.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9044.78 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 7297.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10171.95, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8195.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 7892.81, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5950.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 8981.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5104.52 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5613.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9035.42 } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 1", "code_information": [ { "code": "3141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8097.04, "maximum": 8663.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8663.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH MCC", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17863, "minimum": 17863.4, "maximum": 32368.517, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17863.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18042.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30022.29 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28967.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23222.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 17863.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32368.52, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26080.59, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25115.97, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18935.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17863.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17863.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28581.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20204.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30022.29 } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 3", "code_information": [ { "code": "7223", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6444.35, "maximum": 6895.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 2", "code_information": [ { "code": "3162", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9594.97, "maximum": 10266.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10266.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITHOUT CCMCC", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6437, "minimum": 6437.94, "maximum": 11665.5473, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6502.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10513.25 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10245.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8369.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11665.55, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9399.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9051.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6824.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10300.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8137.42 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6437.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10513.25 } ] } ] }, { "description": "Fixation Of Knee Joint", "code_information": [ { "code": "27570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 2058, "minimum": 111.61, "maximum": 10500, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2078.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2881.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3004.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2893.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2181.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CCMCC", "code_information": [ { "code": "513", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15443, "minimum": 12063.14, "maximum": 27982.7885, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15443.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15597.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24860.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26228.24 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20075.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15443.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27982.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22546.84, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21712.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16369.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15443.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15443.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24708.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15443.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18533.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15443, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24860.61 } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 3", "code_information": [ { "code": "3413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8036.62, "maximum": 8599.18, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8599.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH CC", "code_information": [ { "code": "389", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7958, "minimum": 6887.53, "maximum": 14421.11, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8038.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13236.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12885.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10346.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14421.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11619.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11189.89, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8436.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12733.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6887.53 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13236.1 } ] } ] }, { "description": "HAND PROCEDURES FOR INJURIES", "code_information": [ { "code": "906", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19163, "minimum": 14400, "maximum": 45303.74, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19163.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19355.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36037.65 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30444.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24912.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 19163.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34724.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27979.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26944.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20313.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19163.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19163.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30662.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22204.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19163.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36037.65 } ] } ] }, { "description": "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC", "code_information": [ { "code": "563", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8967, "minimum": 8771.91, "maximum": 18214.48, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9056.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14758.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14491.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11657.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16248.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13091.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12607.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9505.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14347.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8771.91 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8967.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14758.51 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH MCC", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14512, "minimum": 14512.86, "maximum": 26297.3023, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14512.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14658.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24271.13 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23518.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18866.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 14512.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26297.3, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21188.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 20405.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15383.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14512.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14512.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23220.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14923.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24271.13 } ] } ] }, { "description": "FOOT PROCEDURES WITH MCC", "code_information": [ { "code": "503", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27051, "minimum": 27051.69, "maximum": 49017.6623, "payers_information": [ { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35036.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43700.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 27051.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27322.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43700.91 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43393.91 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 35167.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 27051.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 49017.66, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 39495.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 38034.68, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28674.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27051.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27051.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27051.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43282.7, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 1", "code_information": [ { "code": "3421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4320.97, "maximum": 4623.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4623.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "505", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17527, "minimum": 17100.2, "maximum": 31760.0112, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17702.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27598.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22785.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31760.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25590.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 24643.81, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18579.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28044.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17100.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17527.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.73 } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 2", "code_information": [ { "code": "3422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5791.33, "maximum": 6196.72, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6196.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 4", "code_information": [ { "code": "3414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14089.79, "maximum": 15076.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15076.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF FEMUR WITH MCC", "code_information": [ { "code": "533", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15380, "minimum": 9511.98, "maximum": 27868.6868, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15380.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15533.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25179.3 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26396.52 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19994.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 15380.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27868.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22454.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21624.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16302.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15380.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15380.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24608.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20186.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25179.3 } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 3", "code_information": [ { "code": "3163", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14722.67, "maximum": 15753.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15753.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 3", "code_information": [ { "code": "3423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8404.47, "maximum": 8992.78, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8992.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY", "code_information": [ { "code": "934", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21513, "minimum": 4341.23, "maximum": 38982.5345, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21513.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21728.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35431.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33857.25 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27967.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 21513.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38982.53, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31409.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 30248.04, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22804.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21513.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21513.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34421.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4341.23 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21513.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35431.66 } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 4", "code_information": [ { "code": "3164", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24919.77, "maximum": 26664.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26664.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF FEMUR WITHOUT MCC", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8114, "minimum": 6192.22, "maximum": 15127.6, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8195.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13440.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13106.03 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10548.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14702.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11846.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11408.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8601.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12982.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6192.22 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8114.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13440.85 } ] } ] }, { "description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "514", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10176, "minimum": 10176.79, "maximum": 37605.42, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10787.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10176.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10176.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16282.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11615.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16835.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10176.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10278.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16835.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16851.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13229.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 10176.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18440.34, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14858.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14308.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10176.8, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 2", "code_information": [ { "code": "2462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6330.92, "maximum": 6774.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6774.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Education&Training Self-Mgmt Nonphys 1 Pt", "code_information": [ { "code": "98960", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 346, "minimum": 26.66, "maximum": 346, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.99 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 36.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.53 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 4", "code_information": [ { "code": "2464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13256.55, "maximum": 14184.51, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14184.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc R&L Hrt Cath Chd Img Cath Trgt Zone Nml Nt Connj", "code_information": [ { "code": "93596", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14807.6, "discounted_cash": 4149, "minimum": 365.967, "maximum": 14807.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 365.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6223.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4190.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5808.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6057.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5833.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4398.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 4", "code_information": [ { "code": "2324", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27793.7, "maximum": 29739.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29739.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Vnpnxr 3 Years/> Phys/Qhp Skill", "code_information": [ { "code": "36410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 531, "minimum": 15.49, "maximum": 531, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH CC", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9779, "minimum": 9779.91, "maximum": 17721.1969, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9877.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16279.28 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15918.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12713.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17721.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14278.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13750.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10366.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15647.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10430.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9779.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16279.28 } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 1", "code_information": [ { "code": "2461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5157.39, "maximum": 5518.41, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5518.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 3", "code_information": [ { "code": "2463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9026.75, "maximum": 9658.62, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9658.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 1", "code_information": [ { "code": "3161", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7086.77, "maximum": 7582.84, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7582.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Hc Open Tx Articular Fracture Mcp/Ip Joint Ea", "code_information": [ { "code": "26746", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13116.7, "discounted_cash": 4187, "minimum": 323.61, "maximum": 13116.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 339.79 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 346.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc (Sup Shell A4606) Oxygen Probe Used W Oximeter", "code_information": [ { "code": "A4606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 81, "10th_percentile": 69.83, "90th_percentile": 104.26, "count": "23" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 65.1, "10th_percentile": 65.1, "90th_percentile": 83.7, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A4657) Syringe W/Wo Needle", "code_information": [ { "code": "A4657", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 4, "10th_percentile": 4, "90th_percentile": 4, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A6457) Tubular Dressing - A6457 - 27090041", "code_information": [ { "code": "A6457", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 16.2, "10th_percentile": 16.2, "90th_percentile": 16.2, "count": "1 through 10" } ] } ] }, { "description": "Hc 2D Tte W Or W/O Fol W/Con Complete - 93307 - 48300011", "code_information": [ { "code": "93307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5670.26, "discounted_cash": 305, "minimum": 129.18, "maximum": 5670.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 226.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 2D Tte W Or W/O Fol W/Con Complete - C8923 - 48300011", "code_information": [ { "code": "C8923", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5670.26, "discounted_cash": 1003, "minimum": 1003.31, "maximum": 5670.26, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1464.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1410.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1063.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Abdom Paracentesis Dx/Ther W/O Imaging Guidance", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8771.59, "discounted_cash": 1160, "minimum": 58.45, "maximum": 8771.59, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acth Stimj Panel 3 Beta-Hydroxydehyd Defncy", "code_information": [ { "code": "80406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1073.5, "discounted_cash": 78, "minimum": 62.61, "maximum": 1073.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 117.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 79.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 109.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 110.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 66.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 82.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.1, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Activated Prot C (Apc) Resistnce Assay", "code_information": [ { "code": "85307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 76.6, "discounted_cash": 15, "minimum": 10.9, "maximum": 76.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 21.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acylcarnitines Quant", "code_information": [ { "code": "82017", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.55, "discounted_cash": 16, "minimum": 16.87, "maximum": 206.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Agglutinins; Febrile", "code_information": [ { "code": "86000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.4, "discounted_cash": 6, "minimum": 5.586, "maximum": 64.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Allergen Spec Ige Qualit,Multi", "code_information": [ { "code": "86005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.25, "discounted_cash": 7, "minimum": 7.97, "maximum": 30.25, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-1-Antitrypsin, Pheno", "code_information": [ { "code": "82104", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 197, "discounted_cash": 14, "minimum": 14.46, "maximum": 197, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Abdom Paracentesis Dx/Ther W Imaging Guidance", "code_information": [ { "code": "49083", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6196.8, "discounted_cash": 1160, "minimum": 89.72, "maximum": 6196.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 94.34 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-1-Antitrypsin, Total", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 117.6, "discounted_cash": 13, "minimum": 13.44, "maximum": 117.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ablate L/R Atrial Fibril W Isolated Pulm Vein", "code_information": [ { "code": "93657", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20364, "minimum": 329.97, "maximum": 20364, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1408.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 353.07 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 } ] } ] }, { "description": "Hc Alpha-Fetoprotein L3", "code_information": [ { "code": "82107", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 398.81, "discounted_cash": 64, "minimum": 45.81, "maximum": 398.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.12 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 90.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acne Surgery Of Skin Abscess", "code_information": [ { "code": "10040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 185.4, "discounted_cash": 256, "minimum": 55.62, "maximum": 185.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.33 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amino Acids, Multiple Qual", "code_information": [ { "code": "82128", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.87, "discounted_cash": 13, "minimum": 5.661, "maximum": 18.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholinesterase Assay", "code_information": [ { "code": "82013", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.26, "discounted_cash": 12, "minimum": 11.178, "maximum": 37.26, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acth Stimulation Panel", "code_information": [ { "code": "80400", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 310.73, "discounted_cash": 32, "minimum": 26.1, "maximum": 310.73, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 48.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 45.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 45.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.97, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amputation Toe Interphalangeal Joint", "code_information": [ { "code": "28825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4735.67, "discounted_cash": 4187, "minimum": 290.51, "maximum": 4735.67, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 305.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.00% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholn Rcptr Blckg Antb", "code_information": [ { "code": "86042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115, "discounted_cash": 18, "minimum": 18.4, "maximum": 115, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Adenovirus Ag Eia", "code_information": [ { "code": "87301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 138.93, "discounted_cash": 11, "minimum": 11.59, "maximum": 138.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Anesth Vag Delivery, Epidural", "code_information": [ { "code": "01967", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1151.33, "minimum": 4.746, "maximum": 1151.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.51 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 } ] } ] }, { "description": "Hc Actin Smooth Muscle Antibody Each", "code_information": [ { "code": "86015", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60.25, "discounted_cash": 12, "minimum": 11.53, "maximum": 60.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Adenovirus, Antibody", "code_information": [ { "code": "86603", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 69, "discounted_cash": 12, "minimum": 12.87, "maximum": 69, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.02 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Extermity Bilat", "code_information": [ { "code": "75716", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18479.6, "discounted_cash": 4041, "minimum": 143.37, "maximum": 18479.6, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Activity Therapy 45Min Or More, Mentl Disabl Php", "code_information": [ { "code": "G0176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 390.49, "minimum": 35, "maximum": 390.49, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.45 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "description": "Hc Admin Hep B Vac - G0010 - 77100010 - 77100010", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 267.7, "discounted_cash": 59, "minimum": 59.92, "maximum": 267.7, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angiography Iliac During Card Cath - 75710 - 32300016", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7478.22, "discounted_cash": 4041, "minimum": 130.84, "maximum": 18479.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Influenza Virus Vac - G0008 - 77100008 - 77100008", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 308.79, "discounted_cash": 59, "minimum": 25, "maximum": 308.79, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ag Detection Polyval If", "code_information": [ { "code": "87300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 138.93, "discounted_cash": 11, "minimum": 4.11, "maximum": 138.93, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angiotensin I Enzyme Test", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 300, "discounted_cash": 14, "minimum": 14.6, "maximum": 300, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Pneumococcal Vac - G0009 - 77100009 - 77100009", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 334.63, "discounted_cash": 59, "minimum": 59.92, "maximum": 334.63, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Agent Nos Assay W/Optic", "code_information": [ { "code": "87899", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.9, "discounted_cash": 16, "minimum": 5.59, "maximum": 206.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.17, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Anoscopy W Biopsy Sing/Mult", "code_information": [ { "code": "46606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8307.5, "discounted_cash": 1531, "minimum": 41.65, "maximum": 8307.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aep Scr Auditory Potential W/Stimuli Auto Alys", "code_information": [ { "code": "92650", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 273.6, "minimum": 25.68, "maximum": 273.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 33.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 } ] } ] }, { "description": "Hc Allergen Specific Igg", "code_information": [ { "code": "86001", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 99.4, "discounted_cash": 7, "minimum": 4.54, "maximum": 99.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens, Mlc, Each", "code_information": [ { "code": "87187", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 155.1, "discounted_cash": 40, "minimum": 12.94, "maximum": 155.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.26, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 56.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 58.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 56.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.92, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Airway Inhalation Treatment", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1253.85, "discounted_cash": 280, "minimum": 16.78, "maximum": 1253.85, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 545.36, "10th_percentile": 545.36, "90th_percentile": 545.36, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 409.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 394.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-Fetoprotein; Amniotic", "code_information": [ { "code": "82106", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68, "discounted_cash": 17, "minimum": 13.8, "maximum": 68, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.39, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens,Agar Diffusn,Ea", "code_information": [ { "code": "87181", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.65, "discounted_cash": 4, "minimum": 1.33, "maximum": 136.65, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Albumin Ischemia Modified", "code_information": [ { "code": "82045", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 323.33, "discounted_cash": 33, "minimum": 24.14, "maximum": 323.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.68 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 47.52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 49.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 47.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amino Acids, 6+ Quant", "code_information": [ { "code": "82139", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.52, "discounted_cash": 16, "minimum": 16.87, "maximum": 130.52, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens,Mic,Each", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 375.44, "discounted_cash": 8, "minimum": 8.62, "maximum": 375.44, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 280.51, "10th_percentile": 280.51, "90th_percentile": 280.51, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Allergen Spec Ige Quant,Each", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116, "discounted_cash": 5, "minimum": 5.22, "maximum": 116, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amp F/Th 1/2 Jt/Phalanx W/Neurect Local Flap", "code_information": [ { "code": "26952", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13116.7, "discounted_cash": 4187, "minimum": 445.91, "maximum": 13116.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 468.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antiepileptics Not Otherwise Specified 1-3 - G0480 - 30100444", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amino Acids, Single Quantitation", "code_information": [ { "code": "82131", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 164.5, "discounted_cash": 22, "minimum": 21.07, "maximum": 164.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.69 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 32.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amputation Of Finger/Thumb", "code_information": [ { "code": "26951", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4735.67, "discounted_cash": 4187, "minimum": 374.88, "maximum": 4735.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 393.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Indirect Ea Antibody Titer", "code_information": [ { "code": "86886", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.5, "discounted_cash": 218, "minimum": 4.84, "maximum": 918.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amniocentesis,Diagnostic", "code_information": [ { "code": "59000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1040.5, "discounted_cash": 1178, "minimum": 82.13, "maximum": 1040.5, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Pulmon Unilat Select", "code_information": [ { "code": "75741", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17368.6, "discounted_cash": 4041, "minimum": 102.44, "maximum": 17368.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antinomyces Antibody", "code_information": [ { "code": "86602", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 108, "discounted_cash": 10, "minimum": 10.18, "maximum": 108, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amputation Metatarsal + Toe,Single", "code_information": [ { "code": "28810", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17355.1, "discounted_cash": 4187, "minimum": 363.13, "maximum": 17355.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 381.29 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Visceral Selectv/Subselec", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37458.6, "discounted_cash": 7121, "minimum": 121.45, "maximum": 37458.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antinuclear Antibodies", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280.19, "discounted_cash": 12, "minimum": 12.09, "maximum": 280.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Adrenal Bilat Select", "code_information": [ { "code": "75733", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7478.22, "discounted_cash": 4041, "minimum": 148.76, "maximum": 7478.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 394.67 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 159.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Detection Nos If", "code_information": [ { "code": "87299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80.5, "discounted_cash": 16, "minimum": 11.59, "maximum": 80.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 22.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aortic Dys/Dilat Genom Seq Ana", "code_information": [ { "code": "81410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2750, "discounted_cash": 504, "minimum": 504, "maximum": 2750, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 756, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 663.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 644.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 705.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 735.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 708.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 534.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 663.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortobifemoral W Cath", "code_information": [ { "code": "75630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11087.8, "discounted_cash": 4041, "minimum": 104.04, "maximum": 11087.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 426.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 1St Hosp/Birthing Center Care Per Day Nml Nb", "code_information": [ { "code": "99460", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 629.75, "discounted_cash": 170, "minimum": 47.2, "maximum": 629.75, "payers_information": [ { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 238.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 629.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 172.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 47.2 } ] } ] }, { "description": "Hc Antibody Hla Class I & Class Ii Antigens Qual", "code_information": [ { "code": "86828", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1050, "discounted_cash": 64, "minimum": 34.47, "maximum": 1050, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 89.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 93.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Trnk/Arm/Leg Ttl 100Sqcm 1St 25 Sqcm", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10739.8, "discounted_cash": 945, "minimum": 72.23, "maximum": 10739.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortogram Thoracic", "code_information": [ { "code": "75600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8137.09, "discounted_cash": 4041, "minimum": 227.44, "maximum": 8137.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 369.19 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 243.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Hla Class Ii High Definition Panel Qual", "code_information": [ { "code": "86833", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 846, "discounted_cash": 325, "minimum": 8.22, "maximum": 846, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 488.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 329.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 456.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 475.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 458.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 345.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Trnk/Arm/Leg Ttl 100Sqcm Ea Ad 25Qsqcm", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 634.38, "minimum": 14.15, "maximum": 634.38, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "description": "Hc Angio Extremity Unilat", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18479.6, "discounted_cash": 4041, "minimum": 130.84, "maximum": 18479.6, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Abl1 Gene Analysis Kinase Domain Variants", "code_information": [ { "code": "81170", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 962.28, "discounted_cash": 300, "minimum": 240, "maximum": 962.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 252 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 450, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 420, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 438 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 421.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 318, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Indir Qual Ea Reagent Cell", "code_information": [ { "code": "86885", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 159.5, "discounted_cash": 218, "minimum": 5.84, "maximum": 916.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Appl Multlay Comprs Arm/Hand", "code_information": [ { "code": "29584", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 639.35, "discounted_cash": 207, "minimum": 12.66, "maximum": 639.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Pulmon Bilat Select", "code_information": [ { "code": "75743", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17368.6, "discounted_cash": 4041, "minimum": 104.21, "maximum": 17368.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ablate Av Node Function", "code_information": [ { "code": "93650", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13778.7, "discounted_cash": 9982, "minimum": 1026.61, "maximum": 13778.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1077.94 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10082.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13150.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12755.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1098.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10581.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13150.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antithrombin Iii Test,Antigen", "code_information": [ { "code": "85301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 108.1, "discounted_cash": 10, "minimum": 10.81, "maximum": 108.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Short Leg Cast,Walker", "code_information": [ { "code": "29425", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1279.4, "discounted_cash": 357, "minimum": 120.16, "maximum": 1279.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 126.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1279.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Anoscopy W Dilation", "code_information": [ { "code": "46604", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8307.5, "discounted_cash": 1531, "minimum": 56.6, "maximum": 8307.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 59.43 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ablate/ Reconstuct Atria, W Othr Proced Limitd", "code_information": [ { "code": "33257", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 74446.9, "minimum": 460.91, "maximum": 74446.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 493.17 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 } ] } ] }, { "description": "Hc App Skn Sub Head/Hnd/Ft/Gnt Ttl 100Sqcm 1St 25 Sqcm", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12604.5, "discounted_cash": 945, "minimum": 83.02, "maximum": 12604.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aquaporin-4 Antibody Elisa", "code_information": [ { "code": "86051", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.53, "discounted_cash": 11, "minimum": 3.459, "maximum": 11.53, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antb Severe Aqt Respir Synd Sars-Cov-2 Covid19", "code_information": [ { "code": "86769", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172, "discounted_cash": 42, "minimum": 42.13, "maximum": 172, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.24 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 63.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 58.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 61.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 59.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 44.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholine Receptor Binding Antibody", "code_information": [ { "code": "86041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115, "discounted_cash": 18, "minimum": 18.4, "maximum": 115, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Head/Hnd/Ft/Gnt Ttl 100Sqcm Ea Ad 25Cm", "code_information": [ { "code": "15276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2480.05, "minimum": 20.48, "maximum": 2480.05, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 } ] } ] }, { "description": "Hc Arc Antihuman Globulin Dir Ea Antiserum", "code_information": [ { "code": "86880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 348.75, "discounted_cash": 75, "minimum": 5.5, "maximum": 348.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antegrade Urography Radiological Supvj & Interpj", "code_information": [ { "code": "74425", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1258.07, "discounted_cash": 446, "minimum": 48.23, "maximum": 1258.07, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholn Rcptr Modlg Antb", "code_information": [ { "code": "86043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.31, "discounted_cash": 12, "minimum": 12.05, "maximum": 75.31, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Trnk/Arm/Leg >=100Sqcm 1St 100Sqcm", "code_information": [ { "code": "15273", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1926.7, "discounted_cash": 2640, "minimum": 172, "maximum": 1926.7, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 184.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 180.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rh Phenotype", "code_information": [ { "code": "86906", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 328.21, "discounted_cash": 47, "minimum": 5.98, "maximum": 328.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens,Enzyme Detection,Each", "code_information": [ { "code": "87185", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 125.55, "discounted_cash": 4, "minimum": 1, "maximum": 125.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acoustic Immitance Testing", "code_information": [ { "code": "92570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.75, "discounted_cash": 164, "minimum": 26.84, "maximum": 589.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 247.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 231.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 174.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Trnk/Arm/Leg >=100Sqcm Ea Add 100Sqcm", "code_information": [ { "code": "15274", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1265.15, "minimum": 36.49, "maximum": 1265.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.04 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 } ] } ] }, { "description": "Hc Arc Cold Agglutinin Screen", "code_information": [ { "code": "86156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.44, "discounted_cash": 8, "minimum": 7.41, "maximum": 109.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Hla Class I High Definition Panel Qual", "code_information": [ { "code": "86832", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 884.17, "discounted_cash": 323, "minimum": 8.22, "maximum": 884.17, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 485.63, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 326.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 426.49, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 413.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 453.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 472.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 455.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 343.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 426.49, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acth Stimulation Panel 21 Hydroxylase Deficiency", "code_information": [ { "code": "80402", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1192.8, "discounted_cash": 86, "minimum": 69.57, "maximum": 1192.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 91.31 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 130.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 114.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 111.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 121.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 126.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 122.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 92.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 114.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Finger Splint Static", "code_information": [ { "code": "29130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 846.21, "discounted_cash": 170, "minimum": 32.04, "maximum": 846.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.64 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 846.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Frozen Blood,Freezing", "code_information": [ { "code": "86930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 218, "minimum": 37.4535, "maximum": 380.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Adjacent Tissue Trns/Reargmt F/C/C/M/N/A/G/H/F 10Sqcm/&Lt", "code_information": [ { "code": "14040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3737.22, "discounted_cash": 2640, "minimum": 483.82, "maximum": 3737.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 508.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3737.22, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Forearm Splint", "code_information": [ { "code": "29126", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 763, "discounted_cash": 170, "minimum": 92.39, "maximum": 763, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 763, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Hemolysins/Agglutinins Auto", "code_information": [ { "code": "86940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 122.76, "discounted_cash": 8, "minimum": 8.37, "maximum": 122.76, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Dir Ea Antiserum", "code_information": [ { "code": "86880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 348.75, "discounted_cash": 75, "minimum": 5.5, "maximum": 348.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aep Hearing Status Deter Broadband Stimuli I&R", "code_information": [ { "code": "92651", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810, "discounted_cash": 276, "minimum": 80.62, "maximum": 810, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 414.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 279.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 386.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 403.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 388.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 292.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Forearm Splint Static", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 846.21, "discounted_cash": 170, "minimum": 75.84, "maximum": 846.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 846.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Elbow", "code_information": [ { "code": "73085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2182.43, "discounted_cash": 446, "minimum": 73.14, "maximum": 2182.43, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 108.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antinuclear Antibodies Titer", "code_information": [ { "code": "86039", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 289.54, "discounted_cash": 11, "minimum": 11.16, "maximum": 289.54, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 15.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Ag Detect Nos, Eia, Mult Step", "code_information": [ { "code": "87449", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 257.5, "discounted_cash": 11, "minimum": 9.64, "maximum": 257.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply/Remove Cranial Fix Dev", "code_information": [ { "code": "20660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3566.25, "discounted_cash": 2058, "minimum": 181.57, "maximum": 3566.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2078.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2881.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3004.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2893.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2181.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ashkenazi Jewish Assoc Dsrdrs Gen Seq Anal 9 Gen", "code_information": [ { "code": "81412", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2100, "discounted_cash": 2448, "minimum": 630, "maximum": 2100, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antistreptolysin O Screen", "code_information": [ { "code": "86063", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.9, "discounted_cash": 5, "minimum": 5.77, "maximum": 109.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.72 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-Fetoprotein, Serum", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 129.55, "discounted_cash": 16, "minimum": 16.77, "maximum": 129.55, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rbc Antigens", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2111.99, "discounted_cash": 458, "minimum": 3.84, "maximum": 2111.99, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 688.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 645.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aspergillus Ag Eia", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61.7, "discounted_cash": 11, "minimum": 6.93, "maximum": 61.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Head/Hnd/Ft/Gnt >=100Sqcm 1St 100Sqcm", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1926.7, "discounted_cash": 2640, "minimum": 177.21, "maximum": 1926.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 186.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 189.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amino Acid Single Qual", "code_information": [ { "code": "82127", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 188.7, "discounted_cash": 14, "minimum": 14.15, "maximum": 188.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.31 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 19.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment/Chem Or Drugs", "code_information": [ { "code": "86970", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 348.75, "discounted_cash": 75, "minimum": 5.694, "maximum": 348.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aspergillus Antibody", "code_information": [ { "code": "86606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 212.5, "discounted_cash": 15, "minimum": 15.05, "maximum": 212.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub Head/Hnd/Ft/Gnt >=100Sqcm Ea Ad 100Sqcm", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1265.15, "minimum": 45.42, "maximum": 1265.15, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "description": "Hc Amino Acids, 2-5 Quant", "code_information": [ { "code": "82136", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.55, "discounted_cash": 19, "minimum": 18, "maximum": 206.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthro Hip Wo Anesth", "code_information": [ { "code": "27093", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1409.87, "minimum": 288.9, "maximum": 1409.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 303.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 309.12 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 } ] } ] }, { "description": "Hc Aspiration And/Or Injection Thyroid Cyst", "code_information": [ { "code": "60300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2896.7, "discounted_cash": 906, "minimum": 84.14, "maximum": 2896.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 90.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Application Of Finger Splint", "code_information": [ { "code": "29131", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 261.85, "discounted_cash": 75, "minimum": 48.07, "maximum": 261.85, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 261.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Androstanediol Glucuronide", "code_information": [ { "code": "82154", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 313.92, "discounted_cash": 28, "minimum": 28.83, "maximum": 313.92, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 40.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 40.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrocentesis Aspir&/Inj Major Jt/Bursa W/Us", "code_information": [ { "code": "20611", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1981.54, "discounted_cash": 392, "minimum": 52.87, "maximum": 1981.54, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.51 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Alkaline Phosphatase ,Isoenzymes", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 147.8, "discounted_cash": 14, "minimum": 14.78, "maximum": 147.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Elbow To Finger Cast", "code_information": [ { "code": "29075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1116.45, "discounted_cash": 357, "minimum": 118.55, "maximum": 1116.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1116.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 126.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Adrenal Unilat Select", "code_information": [ { "code": "75731", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8505.98, "discounted_cash": 4041, "minimum": 136.04, "maximum": 8505.98, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Ankle", "code_information": [ { "code": "73615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2370.55, "discounted_cash": 446, "minimum": 79.92, "maximum": 2370.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Biovlbl Testosterone Direct Measurement", "code_information": [ { "code": "84410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 316.6, "discounted_cash": 51, "minimum": 45.58, "maximum": 316.6, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.86 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 76.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 65.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 71.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 72.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 54.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 } ] } ] }, { "description": "Hc Apply Long Arm Cast", "code_information": [ { "code": "29065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 658.95, "discounted_cash": 357, "minimum": 132.97, "maximum": 658.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.62 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 658.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortogram Abd Serial", "code_information": [ { "code": "75625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18479.6, "discounted_cash": 4041, "minimum": 102.25, "maximum": 18479.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 389.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Alkal Phosphatase,Heat Stabl W/O Total", "code_information": [ { "code": "84078", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 119.28, "discounted_cash": 8, "minimum": 6.384, "maximum": 119.28, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay C-D Transfer Measure", "code_information": [ { "code": "82373", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 221.22, "discounted_cash": 18, "minimum": 7.46, "maximum": 221.22, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.79 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 25.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Long Leg Splint", "code_information": [ { "code": "29505", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1062.3, "discounted_cash": 207, "minimum": 98.8, "maximum": 1062.3, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.74 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1062.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortogram Thor Serial", "code_information": [ { "code": "75605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19042.8, "discounted_cash": 7121, "minimum": 98.32, "maximum": 19042.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Alkaline Phosphatase", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.9, "discounted_cash": 5, "minimum": 4.74, "maximum": 25.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Carbamazepine Free", "code_information": [ { "code": "80157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 177.74, "discounted_cash": 13, "minimum": 8.79, "maximum": 177.74, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.54 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Lower Leg Splint", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 954.21, "discounted_cash": 207, "minimum": 81.17, "maximum": 954.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.23 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 954.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Ea Addnl Selectv Vessel", "code_information": [ { "code": "75774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4529.61, "minimum": 87.74, "maximum": 4529.61, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "Hc Assay Biotinidase", "code_information": [ { "code": "82261", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.95, "discounted_cash": 16, "minimum": 6.885, "maximum": 22.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay For Phencyclidine", "code_information": [ { "code": "83992", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.6, "discounted_cash": 20, "minimum": 20, "maximum": 142.6, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Rigid Leg Cast", "code_information": [ { "code": "29445", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 982.9, "discounted_cash": 357, "minimum": 195.98, "maximum": 982.9, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 209.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 205.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 982.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Intern Mammary", "code_information": [ { "code": "75756", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3623.69, "discounted_cash": 4041, "minimum": 143.9, "maximum": 3623.69, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.7 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay For Collagen Cross Links", "code_information": [ { "code": "82523", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.76, "discounted_cash": 18, "minimum": 18.68, "maximum": 130.76, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Glucose, Body Fluid", "code_information": [ { "code": "82945", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 207.29, "discounted_cash": 3, "minimum": 2.63, "maximum": 207.29, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aquaporin-4 Antb Cba Each Ea", "code_information": [ { "code": "86052", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.05, "discounted_cash": 12, "minimum": 3.615, "maximum": 12.05, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Pelvis", "code_information": [ { "code": "75736", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8505.98, "discounted_cash": 7121, "minimum": 124.31, "maximum": 8505.98, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 133.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Galactose Transferase", "code_information": [ { "code": "82775", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.67, "discounted_cash": 21, "minimum": 8.601, "maximum": 28.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.67 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.76, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay L/S Ratio", "code_information": [ { "code": "83661", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.8, "discounted_cash": 21, "minimum": 17.94, "maximum": 59.8, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.99, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 30.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Cold Agglutinin, Titer", "code_information": [ { "code": "86157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 120.67, "discounted_cash": 8, "minimum": 8.06, "maximum": 145.08, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.04 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.62, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Pulmon Bilat Nonselec", "code_information": [ { "code": "75746", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21710.7, "discounted_cash": 4041, "minimum": 114.47, "maximum": 21710.7, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Lipoprotein Pla2", "code_information": [ { "code": "83698", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 323.33, "discounted_cash": 46, "minimum": 29.56, "maximum": 323.33, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 64.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 67.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 65.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 49.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Acetaminophen - 80329 - 30100036", "code_information": [ { "code": "80329", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.31, "minimum": 176.793, "maximum": 589.31, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 457.72, "10th_percentile": 457.72, "90th_percentile": 930.01, "count": "1 through 10" } ] } ] }, { "description": "Hc Arc Hemolysins & Agglutinins, Incubated", "code_information": [ { "code": "86941", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 164.8, "discounted_cash": 12, "minimum": 12.11, "maximum": 164.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Retro Brachial Angio", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18479.6, "discounted_cash": 4041, "minimum": 130.84, "maximum": 18479.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Aluminum", "code_information": [ { "code": "82108", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.67, "discounted_cash": 25, "minimum": 10.401, "maximum": 34.67, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.67 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 34.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Acth", "code_information": [ { "code": "82024", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 241.38, "discounted_cash": 38, "minimum": 38.62, "maximum": 241.38, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 54.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 54.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Antibody Elution", "code_information": [ { "code": "86860", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1146.04, "discounted_cash": 218, "minimum": 19.14, "maximum": 1146.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.34 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amikacin", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 272.5, "discounted_cash": 15, "minimum": 14.8785, "maximum": 272.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Adp & Amp", "code_information": [ { "code": "82030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280.88, "discounted_cash": 25, "minimum": 25.8, "maximum": 280.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.77 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 36.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Antibody Identification", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2362.11, "discounted_cash": 458, "minimum": 18.96, "maximum": 2362.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 688.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 645.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angrph Cath F-Up Std Tcat Othr Than Thrombylsis", "code_information": [ { "code": "75898", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17368.6, "discounted_cash": 4041, "minimum": 99.85, "maximum": 17368.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Aldosterone", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 211.16, "discounted_cash": 40, "minimum": 40.75, "maximum": 211.16, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 61.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 57.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 57.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreat,Serum Diff Rbc Abso", "code_information": [ { "code": "86978", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 75, "minimum": 11.385, "maximum": 380.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Anoscopy W Remove Foreign Body", "code_information": [ { "code": "46608", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3763.8, "discounted_cash": 1190, "minimum": 154.87, "maximum": 3763.8, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 162.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 165.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1261.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Arsenic", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 229, "discounted_cash": 18, "minimum": 18.97, "maximum": 229, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 26.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amitriptyline - G0480 - 30100408", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 219.24, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 } ] } ] }, { "description": "Hc Arc Rbc Pretreatment,Serum Dilutn", "code_information": [ { "code": "86976", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 37, "minimum": 11.385, "maximum": 380.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 51.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 52.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.77, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Hla Class Ii Phenotype Panel Qual", "code_information": [ { "code": "86831", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 605, "discounted_cash": 81, "minimum": 8.22, "maximum": 605, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 122.82, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 82.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 107.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 104.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 114.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 119.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 115.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 107.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Barbiturates - G0480 - 30100326", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 342.77, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amphetamines - G0480 - 30100323", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 190.35, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment/Den Grad Sep", "code_information": [ { "code": "86972", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 625.6, "discounted_cash": 218, "minimum": 19.11, "maximum": 625.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Treponema Pallidum", "code_information": [ { "code": "86780", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 153.42, "discounted_cash": 13, "minimum": 9.12, "maximum": 153.42, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Chloride", "code_information": [ { "code": "82435", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.88, "discounted_cash": 4, "minimum": 3.45, "maximum": 151.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Androsterone", "code_information": [ { "code": "82160", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 272.24, "discounted_cash": 25, "minimum": 24.255, "maximum": 272.24, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 35.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment/Enzym", "code_information": [ { "code": "86971", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2362.11, "discounted_cash": 218, "minimum": 5.694, "maximum": 2362.11, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antineutrophil Cytoplasmic Antb Titer Ea Antb", "code_information": [ { "code": "86037", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 127.46, "discounted_cash": 12, "minimum": 12.05, "maximum": 127.46, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Lipoprotein,Ldl Cholest", "code_information": [ { "code": "83721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 131.25, "discounted_cash": 10, "minimum": 9.43, "maximum": 131.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Apolipoprotein", "code_information": [ { "code": "82172", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 179, "discounted_cash": 21, "minimum": 15.09, "maximum": 179, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.64, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arterial Cath Prolngd Nfs Ther Chemotx Cutdown", "code_information": [ { "code": "36640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1355.75, "discounted_cash": 4041, "minimum": 121.22, "maximum": 1355.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 127.28 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antistreptolysin O Titer", "code_information": [ { "code": "86060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 140, "discounted_cash": 7, "minimum": 7.3, "maximum": 140, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.58 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 10.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Osmolality", "code_information": [ { "code": "83930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 214.14, "discounted_cash": 6, "minimum": 6.61, "maximum": 214.14, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 214.14, "10th_percentile": 214.14, "90th_percentile": 214.14, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arterial Line Insertion", "code_information": [ { "code": "36620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1727.5, "minimum": 60.35, "maximum": 1727.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 } ] } ] }, { "description": "Hc Antithrombin Iii Test,Activ", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.25, "discounted_cash": 11, "minimum": 11.85, "maximum": 59.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium In Urine", "code_information": [ { "code": "82340", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 190.9, "discounted_cash": 6, "minimum": 6.03, "maximum": 190.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Pku", "code_information": [ { "code": "84030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.91, "discounted_cash": 5, "minimum": 5.5, "maximum": 21.91, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 7.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Wrist", "code_information": [ { "code": "73115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1584.89, "discounted_cash": 446, "minimum": 44.26, "maximum": 1584.89, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Long Arm Splint", "code_information": [ { "code": "29105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 954.21, "discounted_cash": 207, "minimum": 95.06, "maximum": 954.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 954.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 101.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Carotene", "code_information": [ { "code": "82380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.1, "discounted_cash": 9, "minimum": 9.22, "maximum": 46.1, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.31, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cadmium", "code_information": [ { "code": "82300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136, "discounted_cash": 23, "minimum": 23.6, "maximum": 136, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 33.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 33.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Asp/Drain Large Joint/Bursa", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1585.23, "discounted_cash": 392, "minimum": 65.68, "maximum": 1585.23, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Long Leg Cast", "code_information": [ { "code": "29345", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1398.77, "discounted_cash": 357, "minimum": 174.09, "maximum": 1398.77, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 182.79 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1398.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 186.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Chloramphenicol", "code_information": [ { "code": "82415", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172.4, "discounted_cash": 12, "minimum": 12.67, "maximum": 172.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.72 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.69, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcitonin", "code_information": [ { "code": "82308", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 167.44, "discounted_cash": 26, "minimum": 26.79, "maximum": 167.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 37.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 37.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 17-(17-Ks)Ketosteroids", "code_information": [ { "code": "83586", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.65, "discounted_cash": 12, "minimum": 7.095, "maximum": 23.65, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Multlay Comprs Lwr Leg", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1524.71, "discounted_cash": 207, "minimum": 77.81, "maximum": 1524.71, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.7 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1524.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Copper", "code_information": [ { "code": "82525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 77.56, "discounted_cash": 12, "minimum": 12.41, "maximum": 77.56, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium, Ionized", "code_information": [ { "code": "82330", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 321.95, "discounted_cash": 13, "minimum": 13.68, "maximum": 321.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Blood Carbon Dioxide", "code_information": [ { "code": "82374", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121.5, "discounted_cash": 4, "minimum": 1.56, "maximum": 121.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.32, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Short Leg Cast", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 658.95, "discounted_cash": 357, "minimum": 122.3, "maximum": 658.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.42 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 658.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Corticosterone", "code_information": [ { "code": "82528", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 245.12, "discounted_cash": 22, "minimum": 22.52, "maximum": 245.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 31.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Carnitine", "code_information": [ { "code": "82379", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.55, "discounted_cash": 16, "minimum": 16.87, "maximum": 206.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay For Calprotectin Fecal", "code_information": [ { "code": "83993", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 497, "discounted_cash": 19, "minimum": 13.96, "maximum": 497, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.32 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aquaporin-4 Antibody Flow Cytometry Each", "code_information": [ { "code": "86053", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 188.65, "discounted_cash": 37, "minimum": 12.05, "maximum": 188.65, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 52.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 53.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Creatine", "code_information": [ { "code": "82540", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 128, "discounted_cash": 4, "minimum": 4.64, "maximum": 128, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.77 } ] } ] }, { "description": "Hc Assay Of Ceruloplasmin", "code_information": [ { "code": "82390", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 134.25, "discounted_cash": 10, "minimum": 10.74, "maximum": 134.25, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.92 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 15.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 5-Hiaa", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.5, "discounted_cash": 12, "minimum": 12.9, "maximum": 64.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aquatic Therapy/Exercises Ea 15 Min", "code_information": [ { "code": "97113", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 224.03, "discounted_cash": 41, "minimum": 19.98, "maximum": 224.03, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 57.97, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 58.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cyanide", "code_information": [ { "code": "82600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 250.02, "discounted_cash": 19, "minimum": 19.4, "maximum": 250.02, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.49 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 27.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Chromium", "code_information": [ { "code": "82495", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 248.4, "discounted_cash": 20, "minimum": 20.28, "maximum": 248.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.77 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 28.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Acetaminophen - G0480 - 30100036", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.31, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Antihuman Globulin Indir Qual Ea Reagent Cell", "code_information": [ { "code": "86885", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 916.83, "discounted_cash": 218, "minimum": 5.84, "maximum": 916.83, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.63 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Digoxin", "code_information": [ { "code": "80162", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 450.9, "discounted_cash": 13, "minimum": 13.28, "maximum": 450.9, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.61 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.49, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.49, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ck (Cpk)", "code_information": [ { "code": "82550", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 247.51, "discounted_cash": 6, "minimum": 6.51, "maximum": 247.51, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 195.27, "10th_percentile": 195.27, "90th_percentile": 195.27, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Aldolase", "code_information": [ { "code": "82085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.55, "discounted_cash": 9, "minimum": 9.71, "maximum": 48.55, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 13.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Antihuman Globulin Indirect Ea Antibody Titer", "code_information": [ { "code": "86886", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 918.45, "discounted_cash": 218, "minimum": 4.84, "maximum": 918.45, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cpk In Blood", "code_information": [ { "code": "82552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 13, "minimum": 13.39, "maximum": 130, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.77 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Abo", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 846.21, "discounted_cash": 170, "minimum": 2.73, "maximum": 846.21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 623.6, "10th_percentile": 623.6, "90th_percentile": 779.5, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Estriol", "code_information": [ { "code": "82677", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.91, "discounted_cash": 24, "minimum": 9.873, "maximum": 32.91, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Doxepin - G0480 - 30100409", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 189.81, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ammonia", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 437.93, "discounted_cash": 14, "minimum": 14.57, "maximum": 437.93, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 345.56, "10th_percentile": 345.56, "90th_percentile": 345.56, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rh (D)", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 297.79, "discounted_cash": 47, "minimum": 2.82, "maximum": 297.79, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 189.89, "10th_percentile": 189.89, "90th_percentile": 237.36, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Estrone", "code_information": [ { "code": "82679", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 285.6, "discounted_cash": 24, "minimum": 24.95, "maximum": 285.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 34.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ethchlorvynol - 80320 - 30100071", "code_information": [ { "code": "80320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 211.68, "minimum": 63.504, "maximum": 589.31, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 457.72, "10th_percentile": 457.72, "90th_percentile": 465, "count": "1 through 10" } ] } ] }, { "description": "Hc Assay Of Amylase", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 320.95, "discounted_cash": 6, "minimum": 6.48, "maximum": 320.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Frozen Blood Freeze & Thaw Per Unit", "code_information": [ { "code": "86932", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 47, "minimum": 46.4835, "maximum": 380.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ethanol - 80320 - 30100052", "code_information": [ { "code": "80320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.31, "minimum": 63.504, "maximum": 589.31, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 457.72, "10th_percentile": 457.72, "90th_percentile": 465, "count": "1 through 10" } ] } ] }, { "description": "Hc Assay Of Ferritin", "code_information": [ { "code": "82728", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 175.49, "discounted_cash": 13, "minimum": 13.63, "maximum": 175.49, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.54 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 19.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ascorbic Acid", "code_information": [ { "code": "82180", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61.81, "discounted_cash": 9, "minimum": 9.89, "maximum": 61.81, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.68 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 13.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Frozen Blood Thaw Per Unit", "code_information": [ { "code": "86931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 625.6, "discounted_cash": 218, "minimum": 56.1645, "maximum": 625.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.16 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ethanol - G0480 - 30100052", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.31, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Gentamicin", "code_information": [ { "code": "80170", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.58, "discounted_cash": 16, "minimum": 16.38, "maximum": 468.58, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.12 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 22.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Antibody Screen", "code_information": [ { "code": "86850", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.44, "discounted_cash": 66, "minimum": 2.98, "maximum": 475.44, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 100.04, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 67.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 93.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 323.11, "10th_percentile": 323.11, "90th_percentile": 323.11, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 97.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 93.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 70.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ethylene Glycol", "code_information": [ { "code": "82693", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 230, "discounted_cash": 14, "minimum": 14.9, "maximum": 230, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.96 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Glucagon", "code_information": [ { "code": "82943", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21, "discounted_cash": 14, "minimum": 6.3, "maximum": 21, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.08 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Fatty Acids", "code_information": [ { "code": "82725", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.12, "discounted_cash": 18, "minimum": 5.436, "maximum": 18.12, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment,Serum Inhib", "code_information": [ { "code": "86977", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 218, "minimum": 11.385, "maximum": 380.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Fetal Fibronectin", "code_information": [ { "code": "82731", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 671.5, "discounted_cash": 64, "minimum": 44.95, "maximum": 671.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 59 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 90.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Haloperidol", "code_information": [ { "code": "80173", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.82, "discounted_cash": 15, "minimum": 5.946, "maximum": 19.82, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Lipoprotein,Hdl Cholest", "code_information": [ { "code": "83718", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 268.75, "discounted_cash": 8, "minimum": 7.75, "maximum": 268.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment,Serum W Drugs", "code_information": [ { "code": "86975", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 625.6, "discounted_cash": 571, "minimum": 19.11, "maximum": 625.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.07 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 577.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 606.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Galactose", "code_information": [ { "code": "82760", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 152.4, "discounted_cash": 11, "minimum": 11.172, "maximum": 152.4, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.17 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 15.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Hemosiderin, Qual", "code_information": [ { "code": "83070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.75, "discounted_cash": 4, "minimum": 4.75, "maximum": 23.75, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.23 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of C-Peptide", "code_information": [ { "code": "84681", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.06, "discounted_cash": 20, "minimum": 20.46, "maximum": 130.06, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrocentesis Aspir&/Inj Interm Jt/Burs W/Us", "code_information": [ { "code": "20606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1529.54, "discounted_cash": 903, "minimum": 45.05, "maximum": 1529.54, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 912.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1190.13, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1154.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 1264.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1319.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1270.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 957.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1190.13, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.3 } ] } ] }, { "description": "Hc Assay Of Hemoglobin Heat", "code_information": [ { "code": "83065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 112.56, "discounted_cash": 9, "minimum": 8.26, "maximum": 112.56, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.33 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Insulin", "code_information": [ { "code": "83527", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 227.65, "discounted_cash": 12, "minimum": 12.95, "maximum": 227.65, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.13 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Carbamazepine Total", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410, "discounted_cash": 14, "minimum": 14.47, "maximum": 410, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Hip", "code_information": [ { "code": "73525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1454.95, "discounted_cash": 446, "minimum": 78.84, "maximum": 1454.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Histamine", "code_information": [ { "code": "83088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 188.5, "discounted_cash": 29, "minimum": 29.53, "maximum": 188.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 44.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 41.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 41.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.9, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lipase", "code_information": [ { "code": "83690", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 341.37, "discounted_cash": 6, "minimum": 6.89, "maximum": 341.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.33 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.34, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 198.86, "10th_percentile": 83.87, "90th_percentile": 273.1, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 211.65, "10th_percentile": 211.65, "90th_percentile": 211.65, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.08, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Knee Joint", "code_information": [ { "code": "73580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2148.09, "discounted_cash": 446, "minimum": 76.45, "maximum": 2148.09, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.25 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Imipramine - G0480 - 30100017", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 210.78, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 589.31, "10th_percentile": 589.31, "90th_percentile": 589.31, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lipoprotein(A)", "code_information": [ { "code": "83695", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.6, "discounted_cash": 14, "minimum": 9.21, "maximum": 71.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.09 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Corticosteroids", "code_information": [ { "code": "83491", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.84, "discounted_cash": 17, "minimum": 7.152, "maximum": 23.84, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.84 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Shoulder", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1454.95, "discounted_cash": 446, "minimum": 53.81, "maximum": 1454.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.35 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 57.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Iron", "code_information": [ { "code": "83540", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 220.16, "discounted_cash": 6, "minimum": 6.47, "maximum": 220.16, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lithium", "code_information": [ { "code": "80178", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 85.1, "discounted_cash": 6, "minimum": 6.61, "maximum": 85.1, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.93 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi - Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Dibucaine Number", "code_information": [ { "code": "82638", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 166.6, "discounted_cash": 12, "minimum": 12.25, "maximum": 166.6, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.1 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shiled Of CA Triwest", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "COVENTRY fka AETNA Worker Comp", "plan_name": "COVENTRY - fka AETNA - Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "HEALTH NET FEDERAL SERVICES TRICARE", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molin