{ "hospital_name": "West Anaheim Medical Center", "last_updated_on": "2026-09-01", "version": "3.0", "location_name": [ "West Anaheim Medical Center" ], "hospital_address": [ "3033 West Orange Avenue Anaheim, CA 92804" ], "license_information": { "license_number": "060000182", "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": [ "1871501916", "1316248701", "1730526963" ], "standard_charge_information": [ { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4247.97, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15397.76, "additional_payer_notes": "107% 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 : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 5515, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5515, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7148.4, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10855.32, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.45, "additional_payer_notes": "107% 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": 10421, "minimum": 8501.9342, "maximum": 18883.2688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14429.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10421.23, "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": 10068.5, "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": 18804.74 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13547.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13026.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18883.27, "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": 15215, "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": 14652.25, "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": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10421.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10566.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10421.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16152.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16152.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16673.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10421.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10802 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9968.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18804.74 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4007.74, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6393.41, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.74, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20067.03, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18906.74, "additional_payer_notes": "107% 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": 8809, "minimum": 5804.68, "maximum": 31881.9286, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11452.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11012.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15963.1, "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": 12862.1, "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": 12386.38, "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": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8809.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8935.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8809.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13654.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13654.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14095.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8809.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5804.68 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16337.05 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17871.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8430.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8809.66, "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": 8514.37, "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": 16337.05 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10507.09, "additional_payer_notes": "107% 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": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9996, "minimum": 5936, "maximum": 18114.3284, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17246.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9996.87, "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": 9659.27, "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": 16753 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12995.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12496.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18114.33, "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": 14595.43, "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": 14055.6, "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": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9996.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10137.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9996.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15495.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15495.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15994.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9996.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8312.84 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9563.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16753 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3128.08, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6851.33, "additional_payer_notes": "107% 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 AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17452, "minimum": 9745.34, "maximum": 31624.1474, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26697.15 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17452.62, "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": 16849.33, "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": "case rate", "standard_charge_dollar": 27555.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22688.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21815.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31624.15, "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": 25480.83, "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": 24538.38, "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": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17452.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17683.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17452.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 27051.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27051.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27924.19, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9745.34 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16682.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27555.24 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5317.63, "additional_payer_notes": "107% 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 & 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8710.35, "additional_payer_notes": "107% 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": 27430, "minimum": 22165.8034, "maximum": 49704.1747, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46846.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 27430.56, "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": 26471.6, "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": 47737.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 35659.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 34288.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 49704.17, "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": 40048.62, "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": 38567.37, "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": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 27430.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27782.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27430.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 42517.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 42517.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43888.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37837.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 26209.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47737.13 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4125.47, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4294.49, "additional_payer_notes": "107% 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 & 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14124.4, "additional_payer_notes": "107% 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": 9692, "minimum": 9272.85, "maximum": 19604.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19604.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9692.33, "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": 9365.58, "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": 17109.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12600.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12115.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17562.5, "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": 14150.8, "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": 13627.42, "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": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9692.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9829.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9692.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15023.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15023.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15507.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9692.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13751.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17109.52 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11684.5, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.22, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3565.12, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11743.49, "additional_payer_notes": "107% 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 MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12024, "minimum": 6109.67, "maximum": 23147.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23147.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12024.81, "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": 11614.9, "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": 20328.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15632.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15031.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21788.96, "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": 17556.22, "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": 16906.88, "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": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12024.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12189.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12024.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18638.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18638.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19239.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12024.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6109.67 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11499.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20328.69 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48234.13, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7521.59, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7257.3, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7104.17, "additional_payer_notes": "107% 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 MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8255, "minimum": 3917.88, "maximum": 14958.966, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13450.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8255.5, "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": 7979.96, "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": "case rate", "standard_charge_dollar": 11854.33 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10732.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10319.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14958.97, "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": 12053.03, "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": 11607.23, "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": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8375.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12796.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12796.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13208.8, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8255.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3917.88 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11854.33 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5214.41, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9195.83, "additional_payer_notes": "107% 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 MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9586, "minimum": 9171.79, "maximum": 17370.7199, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16494.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9586.49, "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": 9263.51, "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": 16109.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12462.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11983.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17370.72, "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": 13996.28, "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": 13478.6, "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": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9586.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9722.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9586.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14859.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14859.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15338.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9586.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12996.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16109.86 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9508.9, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10157.72, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5823.53, "additional_payer_notes": "107% 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 MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7629, "minimum": 7303.18, "maximum": 25722.6688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12973.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7629.44, "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": 7376.21, "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": 12672.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9918.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9536.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13824.55, "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": 11138.98, "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": 10726.99, "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": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7629.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7741.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7629.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11825.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11825.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12207.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7629.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11657.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7303.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12672.23 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18265.75, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16196.77, "additional_payer_notes": "107% 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": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22294, "minimum": 18171.3098, "maximum": 40693.41, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40693.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22294.31, "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": 21518.45, "additional_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": 39829 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28982.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27867.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40397.29, "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": 32549.69, "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": 31345.8, "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": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22294.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22583.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22294.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 34556.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 34556.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35670.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22294.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34404.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21305.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39829 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7320, "minimum": 7008.59, "maximum": 13363.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13363.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7320.91, "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": 7078.68, "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": 12950.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9517.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9151.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13265.49, "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": 10688.53, "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": 10293.2, "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": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7320.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7429.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7320.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11347.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11347.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11713.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7320.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10408.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7008.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12950.1 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16276.17, "additional_payer_notes": "107% 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": 16426, "minimum": 11935.4326, "maximum": 29764.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28662.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16426.17, "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": 15859.42, "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": 28685.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21354.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20532.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29764.22, "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": 23982.21, "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": 23095.2, "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": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16426.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16644.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16426.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25460.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25460.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26281.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16426.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19278.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15702.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28685.97 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.33, "additional_payer_notes": "107% 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 MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6389, "minimum": 6119.09, "maximum": 28735.4208, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9811.32 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8829.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6389.31, "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": 6180.28, "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": 9811.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8306.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7986.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11577.43, "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": 9328.39, "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": 8983.37, "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": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6389.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6486.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6389.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 9903.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9903.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10222.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6389.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7886.38 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6119.09, "additional_payer_notes": "100.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27548.92, "additional_payer_notes": "107% 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": 20187, "minimum": 8988.9092, "maximum": 36579.7319, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35616.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20187.49, "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": 19486.74, "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": 34173.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26243.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25234.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36579.73, "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": 29473.74, "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": 28383.61, "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": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20187.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20451.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20187.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31290.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31290.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32299.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20187.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35783.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19293.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34173.6 } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45964, "minimum": 28341.945, "maximum": 85404.2775, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81867.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 45964.58, "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": 44345.06, "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": 85404.28 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 59753.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 57455.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83287.82, "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": 67108.29, "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": 64626.2, "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": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 45964.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46540.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45964.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 71245.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 71245.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 73543.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45964.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68642.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43906, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85404.28 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21235, "minimum": 15836.427, "maximum": 40388.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40388.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21235.91, "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": 20497.75, "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": 37328.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27606.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26544.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38479.47, "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": 31004.43, "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": 29857.69, "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": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21235.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21512.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21235.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 32915.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32915.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33977.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21235.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25537.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37328.11 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25772.59, "additional_payer_notes": "107% 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 WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55225, "minimum": 27086.1988, "maximum": 115241, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101155.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 55225.61, "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": 53276.09, "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": 96597.99 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 71793.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 69032.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 100068.81, "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": 80629.39, "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": 77647.21, "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": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 55225.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55913.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55225.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 85599.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 85599.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88360.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55225.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 115241 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52748.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96597.99 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3142.03, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4126.6, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48465.53, "additional_payer_notes": "107% 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": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12585, "minimum": 12035.7, "maximum": 62388.6398, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12585.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17849.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22207.42 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25508.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12585.96, "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": 12156.06, "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": 22207.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16361.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15732.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22805.76, "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": 18375.5, "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": 17695.86, "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": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12585.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12757.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12585.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 19508.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19508.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20137.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12035.7, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14381, "minimum": 13749.9, "maximum": 45287.3764, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26577.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14381.25, "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": 13887.4, "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": 25043.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18695.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17976.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26058.83, "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": 20996.63, "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": 20220.04, "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": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14381.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14574.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14381.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22290.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22290.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23010, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14381.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20863.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13749.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25043.86 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8887.29, "additional_payer_notes": "107% 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": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6676, "minimum": 6393.66, "maximum": 24922.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11537.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6676.88, "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": 6457.6, "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": 10242.99 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8679.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8346.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12098.51, "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": 9748.24, "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": 9387.69, "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": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6676.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6777.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6676.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10349.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10349.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10683.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6676.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24922.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6393.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10242.99 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2333.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13991.67, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20654.6, "additional_payer_notes": "107% 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, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8436, "minimum": 8073.51, "maximum": 18502.4528, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14095.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8436.23, "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": 8154.25, "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": 14288.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10967.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10545.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15286.45, "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": 12316.9, "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": 11861.34, "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": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8436.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8557.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8436.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13076.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13076.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13497.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8436.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12643.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8073.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14288.81 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9243.46, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4850.3, "additional_payer_notes": "107% 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": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6569, "minimum": 4452, "maximum": 11903.1005, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10379.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6569.04, "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": 6353.61, "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": 10907.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8539.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8211.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11903.1, "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": 9590.8, "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": 9236.07, "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": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6569.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6668.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6569.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10182.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10182.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10510.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6569.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4882.17 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6290.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10907.1 } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12288, "minimum": 8151.3122, "maximum": 31216.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19381.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12288.41, "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": 11869.12, "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": 18857.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15974.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15360.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22266.6, "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": 17941.08, "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": 17277.5, "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": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12288.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12456.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12288.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 19047.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19047.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19661.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12288.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31216.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18857.17 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14544, "minimum": 9313.82, "maximum": 29065.69, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29065.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14544.01, "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": 14044.35, "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": 25304.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18907.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18180.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26353.75, "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": 21234.25, "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": 20448.88, "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": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14544.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14739.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14544.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22543.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22543.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23270.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14544.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9313.82 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13905.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25304.26 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10436.76, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7341.24, "additional_payer_notes": "107% 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": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11653, "minimum": 10439.4454, "maximum": 21115.9064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20453.3 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11653.37, "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": 11256.75, "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": 19900.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15149.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14566.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21115.91, "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": 17013.92, "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": 16384.64, "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": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11653.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11814.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11653.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18062.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18062.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18645.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11653.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19737.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11145.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19900.52 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17834, "minimum": 10176, "maximum": 32315.2805, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32124.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17834.04, "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": 17217.17, "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": 31122.19 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23184.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22292.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32315.28, "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": 26037.7, "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": 25074.66, "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": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17834.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18069.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17834.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 27642.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27642.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28534.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17834.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14835 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17046.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31122.19 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4368.22, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3518.62, "additional_payer_notes": "107% 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": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19030, "minimum": 14623.5346, "maximum": 34482.7949, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33432.41 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19030.24, "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": 18370.69, "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": 32441.67 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24739.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23787.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34482.79, "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": 27784.15, "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": 26756.52, "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": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19030.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19280.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19030.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 29496.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29496.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30448.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19030.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26074.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18188.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32441.67 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9224, "minimum": 6996, "maximum": 16713.9605, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9224.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14297.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14297.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14758.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9224.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15417.79 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15457.86 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9224.04, "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": 8913.98, "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": "case rate", "standard_charge_dollar": 15417.79 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11991.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11530.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16713.96, "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": 13467.1, "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": 12969, "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": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9224.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8825.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9355.26, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17200, "minimum": 8652.5718, "maximum": 32050.31, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32050.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17200, "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": 16605.71, "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": 30372.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22360, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21500, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31166.4, "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": 25112, "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": 24183.2, "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": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17200, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17427.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17200, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 26660, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26660, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27520, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17200, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19485.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16441.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30372.45 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59181.34, "additional_payer_notes": "107% 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": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36536, "minimum": 34904.3, "maximum": 79583.4024, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63849.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 36536.81, "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": 35253.34, "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": 62342.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 47497.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 45671.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 66204.7, "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": 53343.74, "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": 51370.75, "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": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 36536.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36998.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36536.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 56632.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 56632.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58458.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36536.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50107.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34904.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62342.26 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5223.48, "additional_payer_notes": "107% 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": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7062, "minimum": 5589.56, "maximum": 20367.2424, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11902.33 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7062.3, "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": 6829.28, "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": 11606.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9180.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8827.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12796.89, "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": 10310.96, "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": 9929.59, "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": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7062.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7167.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7062.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10946.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10946.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11299.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7062.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5589.56 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6761.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11606.16 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5234.83, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20273.47, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20585.4, "additional_payer_notes": "107% 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", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 120407, "minimum": 114985, "maximum": 228973.9221, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 207060.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 120407.23, "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": 116134.85, "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": 228973.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 156529.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 150509.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 218177.9, "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": 175794.56, "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": 169292.57, "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": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 120407.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 121884.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 120407.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 186631.21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 186631.21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 192651.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 120407.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 148633 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 114985, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 228973.92 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5078.29, "additional_payer_notes": "107% 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 : 1", "code_information": [ { "code": "8111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2829.41, "maximum": 3027.47, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3027.47, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71097.23, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6864.83, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8585.57, "additional_payer_notes": "107% 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- SOI : 4", "code_information": [ { "code": "0074", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 149835.59, "maximum": 160324.08, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 160324.08, "additional_payer_notes": "107% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16223.99, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 95522.26, "additional_payer_notes": "107% 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": "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": 14232, "minimum": 13607.8, "maximum": 41461.7008, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25184.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14232.48, "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": 13743.88, "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": 26387.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18502.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17790.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25789.25, "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": 20779.42, "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": 20010.87, "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": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14232.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14424.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14232.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22060.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22060.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22771.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21209.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26387.8 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6939.69, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9738.03, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19795.93, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16330.62, "additional_payer_notes": "107% 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 WITH CC", "code_information": [ { "code": "240", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 28871, "minimum": 17977.8184, "maximum": 52314.9406, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50752.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 28871.38, "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": 27861.05, "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": 50895.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 37532.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 36089.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 52314.94, "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": 42152.21, "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": 40593.16, "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": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 28871.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29240.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 28871.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 44750.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 44750.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 46194.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 28871.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26372.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 27585.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50895.13 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8792.02, "additional_payer_notes": "107% 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 CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23132, "minimum": 22105.3, "maximum": 41915.2746, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38747.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23132.05, "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": 22326.35, "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": 37702.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30071.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28915.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41915.27, "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": 33772.79, "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": 32523.66, "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": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23132.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23431.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23132.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 35854.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 35854.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37011.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23132.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26459.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22105.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37702.11 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13777.29, "additional_payer_notes": "107% 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 FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12193, "minimum": 10888.1, "maximum": 22094.7126, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21262.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12193.55, "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": 11777.61, "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": 20326.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15851.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15241.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22094.71, "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": 17802.58, "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": 17144.13, "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": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12193.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12360.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12193.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18900, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18900, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19509.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12193.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10888.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11661, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20326.95 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9102, "minimum": 8709.41, "maximum": 19797.157, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17629.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9102.22, "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": 8796.5, "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": 15395.07 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11832.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11377.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16493.22, "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": 13289.24, "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": 12797.72, "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": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9102.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9231.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9102.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14108.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14108.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14563.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9102.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9339.13 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8709.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15395.07 } ] } ] }, { "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": 49552, "minimum": 37016.593, "maximum": 89788.532, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86842.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 49552.17, "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": 47804.82, "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": 88027.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 64417.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 61940.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 89788.53, "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": 72346.17, "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": 69670.35, "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": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 49552.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50171.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 49552.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 76805.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 76805.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 79283.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 49552.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50079.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 47331.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88027.5 } ] } ] }, { "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": 35230, "minimum": 24287.7158, "maximum": 71502.53, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71502.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 35230.78, "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": 33993.87, "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": 67546.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 45800.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 44038.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63838.17, "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": 51436.94, "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": 49534.48, "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": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 35230.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35676.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35230.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 54607.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 54607.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56369.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35230.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31071 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33657.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67546.77 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9165.88, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10065.84, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.79, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27433.95, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33405.34, "additional_payer_notes": "107% 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 : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 6695.81, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6695.81, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3476.19, "additional_payer_notes": "107% 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": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43273, "minimum": 41336.7, "maximum": 78411.8538, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77737.35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 43273.65, "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": 41750.07, "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": 78376.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 56255.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 54092.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 78411.85, "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": 63179.53, "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": 60842.75, "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": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43273.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43816.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43273.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 67074.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 67074.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69237.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43273.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 72997.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 41336.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78376.97 } ] } ] }, { "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": 14570, "minimum": 13931, "maximum": 37495.7764, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 20486.78, "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": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14570.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14766.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14570.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22585, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22585, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23313.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14570.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17490 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21760.02 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20984.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14570.97, "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": 14070.31, "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": 21760.02 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13931, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18942.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18213.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26402.6, "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": 21273.62, "additional_payer_notes": "146.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7852.8, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.57, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13461.96, "additional_payer_notes": "107% 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 : 4", "code_information": [ { "code": "2264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21704.49, "maximum": 23223.8, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23223.8, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17721.28, "additional_payer_notes": "107% 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": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42577, "minimum": 8679.83, "maximum": 77150.7924, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75132.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 42577.7, "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": 41078.92, "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": "case rate", "standard_charge_dollar": 72714.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 55351.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 53222.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 77150.79, "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": 62163.44, "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": 59864.25, "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": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 42577.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43112.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42577.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 65995.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 65995.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 68124.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42577.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8679.83 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40672.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72714.57 } ] } ] }, { "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": 19084, "minimum": 18240.3, "maximum": 35853.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35853.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19084.15, "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": 18422.7, "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": 33757.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24809.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23855.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34580.48, "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": 27862.86, "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": 26832.31, "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": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19084.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19334.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19084.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 29580.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29580.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30534.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19084.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19236.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18240.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33757.65 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23330, "minimum": 11305.6116, "maximum": 46053.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46053.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23330.75, "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": 22517.95, "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": 41363.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30329.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 29163.44, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42275.32, "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": 34062.9, "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": 32803.03, "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": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23330.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23632.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23330.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 36162.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 36162.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37329.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23330.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33245 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22295, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41363.44 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4665.3, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23121.72, "additional_payer_notes": "107% 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": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13477, "minimum": 12887.1, "maximum": 32359.8134, "payers_information": [ { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22001.2 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23511.99 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13477.62, "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": 13015.97, "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": 22001.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17520.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16847.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24421.45, "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": 19677.33, "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": 18949.53, "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": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13477.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13660.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13477.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20890.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20890.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21564.19, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13477.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17005.3 } ] } ] }, { "description": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5278.75, "minimum": 146.17, "maximum": 5278.75, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "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 : 4", "code_information": [ { "code": "5664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13254.22, "maximum": 14182.02, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14182.02, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4263.86, "additional_payer_notes": "107% 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": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7417, "minimum": 7101.07, "maximum": 27078.4072, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12612.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7417.76, "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": 7172.08, "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": 12203.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9643.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9272.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13440.98, "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": 10829.93, "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": 10429.37, "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": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7417.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7527.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7417.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11497.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11497.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11868.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7417.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8354.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12203.86 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9338.75, "additional_payer_notes": "107% 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": "ASTHMA - SOI : 3", "code_information": [ { "code": "1413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6672.27, "maximum": 7139.33, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7139.33, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11657.28, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5172.44, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12031.59, "additional_payer_notes": "107% 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": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7131, "minimum": 6593.08, "maximum": 20463.3388, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11889.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7131.19, "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": 6895.72, "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": 11751.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9270.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8913.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12921.72, "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": 10411.54, "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": 10026.45, "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": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7131.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7237.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7131.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11053.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11053.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11409.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7131.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6593.08 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6827.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11751.21 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4521.35, "additional_payer_notes": "107% 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 : 1", "code_information": [ { "code": "2341", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7065.57, "maximum": 7560.16, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7560.16, "additional_payer_notes": "107% 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": "Av Fusion Direct Any Site", "code_information": [ { "code": "36821", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15750, "discounted_cash": 4041, "minimum": 623.2, "maximum": 15750, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 666.82 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 623.2 }, { "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 Health Plan", "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": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 69084, "minimum": 19094.6, "maximum": 125181.4583, "payers_information": [ { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 107081.27, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 110535.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 69084.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19094.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116526.47 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 123841.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 69084.69, "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": 66641.21, "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": 116526.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 89810.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 86355.86, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 125181.46, "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": 100863.65, "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": 97133.07, "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": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 69084.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 69940.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 69084.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 65981.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 107081.27, "additional_payer_notes": "155.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14144.35, "additional_payer_notes": "107% 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": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15522, "minimum": 14839.6, "maximum": 33095.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27340.32 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15522.53, "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": 14988, "additional_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": 26445.48 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20179.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19403.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28126.82, "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": 22662.89, "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": 21824.68, "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": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15729.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24059.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24059.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24836.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33095.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14839.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26445.48 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17117.83, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2426.85, "additional_payer_notes": "107% 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": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15325, "minimum": 14651.8, "maximum": 37272.4172, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25862.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15325.83, "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": 14798.32, "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": 25047.35 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19923.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19157.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27770.4, "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": 22375.71, "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": 21548.12, "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": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15325.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15530.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15325.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 23755.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 23755.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24521.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15325.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22093.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14651.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25047.35 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9643.88, "additional_payer_notes": "107% 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 : 4", "code_information": [ { "code": "2334", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24117.27, "maximum": 25805.48, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25805.48, "additional_payer_notes": "107% 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": "Artery-Vein Nonautograft", "code_information": [ { "code": "36830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18375, "discounted_cash": 7121, "minimum": 834.68, "maximum": 18375, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 893.11 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 834.68 }, { "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 Health Plan", "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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8895.23, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14329.7, "additional_payer_notes": "107% 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": "ASTHMA - SOI : 2", "code_information": [ { "code": "1412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4806.49, "maximum": 5142.94, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5142.94, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27517.16, "additional_payer_notes": "107% 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": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24322, "minimum": 23241.7, "maximum": 44071.917, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40588.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24322.25, "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": 23474.12, "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": 43303.33 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31618.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30402.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44071.92, "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": 35510.49, "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": 34197.08, "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": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24322.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24636.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24322.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 37699.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 37699.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38915.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24322.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36806.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43303.33 } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24675.3, "maximum": 39224.213, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24680.9 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30701.01 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24675.3 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30701.01 } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12357, "minimum": 9805.7286, "maximum": 22391.4457, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20254.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12357.31, "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": 11935.57, "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": 20330.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16064.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15446.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22391.45, "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": 18041.67, "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": 17374.38, "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": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12357.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12526.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12357.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 19153.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19153.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19771.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12357.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16341 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11817.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20330.44 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26162, "minimum": 24998.7, "maximum": 47406.3956, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43074.6 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 26162.47, "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": 25248.69, "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": 41894.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 34011.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32703.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47406.4, "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": 38197.21, "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": 36784.43, "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": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26498.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 40551.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 40551.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41859.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32232.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41894.72 } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11839, "minimum": 11322.6, "maximum": 21452.4311, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20110.03 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11839.09, "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": 11435.83, "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": "case rate", "standard_charge_dollar": 19640.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15390.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14798.86, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21452.43, "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": 17285.07, "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": 16645.76, "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": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11839.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12001.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11839.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18350.59, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18350.59, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18942.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21287.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19640.12 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11979.42, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24372.86, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36981.81, "additional_payer_notes": "107% 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": "ASTHMA - SOI : 1", "code_information": [ { "code": "1411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3243.91, "maximum": 3470.98, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3470.98, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45694.42, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69665.73, "additional_payer_notes": "107% 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": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC", "code_information": [ { "code": "461", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55556, "minimum": 53064.1, "maximum": 123187.72, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 123187.72 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 55556.11, "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": 53594.74, "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": 107248.18 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 72222.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 69445.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 100667.67, "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": 81111.92, "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": 78111.89, "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": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 55556.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56247.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55556.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 86111.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 86111.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88889.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55556.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 86199.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 53064.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107248.18 } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59616, "minimum": 56941.5, "maximum": 111597.93, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 59616.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60357.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59616.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 92406.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 92406.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 95387.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59616.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63563 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105486.55 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111597.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 59616.98, "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": 57510.92, "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": "case rate", "standard_charge_dollar": 105486.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 77502.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 74521.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 108025.97, "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": 87040.79, "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": 83821.47, "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": 56941.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": 16262, "minimum": 15546, "maximum": 29467.4869, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28277.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16262.41, "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": 15701.46, "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": "case rate", "standard_charge_dollar": 27107.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21141.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20328.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29467.49, "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": 23743.12, "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": 22864.95, "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": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16262.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16478.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16262.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25206.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25206.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26019.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16262.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26231.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27107.84 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31216.13, "additional_payer_notes": "107% 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 WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54650, "minimum": 52199.4, "maximum": 111597.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111597.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 54650.48, "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": 52721.39, "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": 105486.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 71045.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 68313.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 99026.67, "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": 79789.7, "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": 76838.57, "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": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 54650.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55331.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 54650.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 84708.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 84708.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 87440.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 54650.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 84783.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52199.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105486.55 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14612.14, "additional_payer_notes": "107% 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": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13352, "minimum": 10779.6786, "maximum": 24417.13, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24417.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13352.8, "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": 12895.58, "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": 22824.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17358.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16691, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24195.27, "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": 19495.09, "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": 18774.04, "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": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13352.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13533.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13352.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20696.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20696.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21364.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13352.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18345.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22824.34 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11811.54, "additional_payer_notes": "107% 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": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20381, "minimum": 19399.7854, "maximum": 36930.7344, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35566.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20381.2, "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": 19673.49, "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": 34461.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26495.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25476.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36930.73, "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": 29756.55, "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": 28655.97, "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": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20381.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20647.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20381.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31590.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31590.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32609.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20381.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28200.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19478.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34461.96 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11205.82, "additional_payer_notes": "107% 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": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35550, "minimum": 33962.3, "maximum": 65450.19, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35550.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 55102.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 55102.97, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56880.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35550.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 41757.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63766.59 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65450.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 35550.3, "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": 34301.92, "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": "case rate", "standard_charge_dollar": 63766.59 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 46215.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 44437.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 64417.14, "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": 51903.44, "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": 49983.72, "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": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 35550.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 33962.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36000.04, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "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": 37726, "minimum": 25974.5972, "maximum": 68359.5482, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65975.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 37726.02, "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": 36400.2, "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": 62635.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 49043.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 47157.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 68359.55, "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": 55079.99, "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": 53042.78, "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": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 37726.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 38202.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 37726.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 58475.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 58475.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 60361.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 37726.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 41700.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 36039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62635.86 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16711.74, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2583.95, "additional_payer_notes": "107% 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": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21131, "minimum": 9752, "maximum": 38289.4988, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30382.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21131.07, "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": 20396.65, "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": 31396.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27470.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26413.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38289.5, "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": 30851.36, "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": 29710.28, "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": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21131.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21406.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21131.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 32753.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32753.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33809.71, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21131.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15536.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20194.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31396.58 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12093, "minimum": 9375.892, "maximum": 22418.95, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22418.95 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12093.71, "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": 11681.36, "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": 22065.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15721.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15117.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21913.8, "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": 17656.82, "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": 17003.76, "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": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12093.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12259.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12093.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18745.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18745.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19349.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12093.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17735.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22065.86 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26162, "minimum": 17692.1264, "maximum": 47406.3956, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39379.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 26162.47, "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": 25248.69, "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": 41894.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 34011.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32703.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47406.4, "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": 38197.21, "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": 36784.43, "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": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26498.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 40551.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 40551.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41859.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26162.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24647.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24998.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41894.72 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7099, "minimum": 5983.12, "maximum": 12863.8229, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12554.54 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7099.24, "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": 6864.91, "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": 12174.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9229.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8874.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12863.82, "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": 10364.89, "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": 9981.53, "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": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7099.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7204.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7099.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11003.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11003.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11358.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7099.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5983.12 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12174.15 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4466.9, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3607.1, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7268.64, "additional_payer_notes": "107% 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": "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": 36011, "minimum": 34402.8, "maximum": 73807, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67247.83 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 36011.61, "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": 34746.83, "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": "case rate", "standard_charge_dollar": 61190.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 46815.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 45014.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 65253.04, "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": 52576.95, "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": 50632.32, "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": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 36011.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36466.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36011.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 55818, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 55818, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 57618.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36011.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 73807 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34402.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61190.55 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7618, "minimum": 4930.26, "maximum": 19256.9394, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13204.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7618.46, "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": 7365.62, "additional_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": 13009.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9904, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9523.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13804.65, "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": 11122.95, "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": 10711.55, "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": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7618.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7730.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7618.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11808.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11808.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12189.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7618.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4930.26 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7292.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13009.52 } ] } ] }, { "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": 22149, "minimum": 21167.1, "maximum": 40134.9484, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35361.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22149.53, "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": 21378.77, "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": 36639.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28794.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27686.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40134.95, "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": 32338.31, "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": 31142.24, "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": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22149.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22437.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22149.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 34331.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 34331.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35439.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22149.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34285.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21167.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36639.53 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34903, "minimum": 33344.6, "maximum": 63244.7434, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60866.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 34903.28, "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": 33678.05, "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": 60101.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 45374.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 43629.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63244.74, "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": 50958.79, "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": 49074.01, "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": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 34903.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35345.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34903.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 54100.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 54100.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55845.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34903.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 56528.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33344.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60101.77 } ] } ] }, { "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": 26969, "minimum": 25769.1, "maximum": 51423.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51423.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 26969.25, "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": 26026.79, "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": 50049.27 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 35060.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 33711.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 48868.28, "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": 39375.11, "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": 37918.77, "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": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 26969.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27315.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26969.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 41802.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 41802.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43150.8, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26969.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30071.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25769.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50049.27 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24964, "minimum": 23854.7, "maximum": 45235.2754, "payers_information": [ { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31205.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45235.28, "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": 36447.85, "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": 35099.78, "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": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24964.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25285.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24964.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 38694.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 38694.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39942.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24964.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25223.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40870.6 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43065.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24964.28, "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": 24093.25, "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": 40870.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23854.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32453.56, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18970, "minimum": 18131.6, "maximum": 34374.238, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33676.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18970.33, "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": 18312.92, "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": "case rate", "standard_charge_dollar": 31034.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24661.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23712.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34374.24, "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": 27696.68, "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": 26672.28, "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": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18970.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19219.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18970.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 29404.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29404.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30352.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18970.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21194 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18131.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31034.81 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4573.52, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8068.32, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3644.53, "additional_payer_notes": "107% 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": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8697, "minimum": 7038.52, "maximum": 17164.8948, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14847.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8697.83, "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": 8406.52, "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": 14585.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11307.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10872.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15760.47, "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": 12698.83, "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": 12229.15, "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": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8697.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8822.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8697.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13481.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13481.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13916.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7038.52 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8323.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14585.91 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8354.17, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3384.77, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8075.13, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9088.07, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11759.36, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5199.66, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27049.81, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5000.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "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" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7196.04, "additional_payer_notes": "107% 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": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19671, "minimum": 18800.9, "maximum": 38277.8, "payers_information": [ { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 30490.47, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31474.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19671.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38277.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34692.65 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30424.3 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19671.27, "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": 18988.91, "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": 34692.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25572.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24589.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35644.34, "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": 28720.05, "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": 27657.81, "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": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19671.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19928.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19671.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18800.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 30490.47, "additional_payer_notes": "155.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46524, "minimum": 44440.9, "maximum": 86402.13, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86402.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 46524.74, "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": 44885.31, "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": 81299.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 60482.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 58155.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 84302.83, "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": 67926.12, "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": 65413.78, "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": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 46524.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47107.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46524.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 72113.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 72113.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74439.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46524.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 67798.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 44440.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81299.04 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10133.9, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19256, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29055.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15663.64, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17739.42, "additional_payer_notes": "107% 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": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21784, "minimum": 20818.2, "maximum": 40467, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35385.42 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21784.08, "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": 21026.38, "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": 35781.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28319.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27230.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39472.75, "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": 31804.76, "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": 30628.42, "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": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21784.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22067.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21784.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 33765.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 33765.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34854.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21784.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 40467 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20818.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35781.44 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4100.52, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30389.22, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.61, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24358.11, "additional_payer_notes": "107% 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": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10106, "minimum": 9256.88, "maximum": 23777.366, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17298.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10106.7, "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": 9765.19, "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": 16894.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13138.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12633.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18313.34, "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": 14755.78, "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": 14210.02, "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": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10106.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10248.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10106.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15665.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15665.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16170.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10106.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9256.88 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9668.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16894.56 } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31782, "minimum": 26258.9906, "maximum": 57590.7779, "payers_information": [ { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49030.39 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48935.43 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 31782.99, "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": 30668.95, "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": 49030.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 41317.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39728.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57590.78, "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": 46403.17, "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": 44686.88, "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": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 31782.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32187.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31782.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 49263.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 49263.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50852.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30365.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31782.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39407.8 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14079.02, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11033.4, "additional_payer_notes": "107% 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 PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19285, "minimum": 18432.9, "maximum": 35105.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33997.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19285.85, "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": 18617.23, "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": 33163.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25071.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24107.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34945.96, "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": 28157.34, "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": 27115.91, "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": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19285.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19538.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19285.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 29893.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29893.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30857.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19285.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35105.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18432.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33163.45 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99001.18, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34529.44, "additional_payer_notes": "107% 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 PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32888, "minimum": 24550.033, "maximum": 74767.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59894.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 32888.32, "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": 31734.91, "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": 59528.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 42754.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 41110.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59593.64, "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": 48016.95, "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": 46240.98, "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": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32888.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33305.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32888.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 50976.9, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 50976.9, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52621.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32888.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 74767.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31420.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59528.54 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16683, "minimum": 15948.4, "maximum": 39703.3964, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29725.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16683.78, "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": 16107.88, "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": 26525.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21688.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20854.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30231.01, "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": 24358.32, "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": 23457.39, "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": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16683.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16905.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16683.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25859.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25859.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26694.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16683.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21320.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26525.87 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.41, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3863.45, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4137.95, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17657.76, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7984.38, "additional_payer_notes": "107% 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 ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4953, "minimum": 4748.14, "maximum": 9346.0242, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7943.92 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 4953.48, "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": 4795.62, "additional_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": 7719.38 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 6439.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 6191.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 8975.71, "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": 7232.08, "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": 6964.59, "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": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 4953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5033.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 7677.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 7677.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7925.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6204.57 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 4748.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7719.38 } ] } ] }, { "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": 98089, "minimum": 85386.8458, "maximum": 177738.9169, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 175342.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 98089.91, "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": 94612.66, "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": 168667.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 127516.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 122612.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 177738.92, "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": 143211.27, "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": 137914.41, "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": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 98089.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 99296.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 98089.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 152039.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 152039.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 156943.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 98089.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 145242 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 93675.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 168667.68 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16004, "minimum": 15300.1, "maximum": 29174, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28964.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16004.8, "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": 15453.1, "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": 28633.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20806.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20006, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29000.7, "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": 23367.01, "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": 22502.75, "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": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16004.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16218.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16004.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24807.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24807.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25607.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16004.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29174 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15300.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28633.54 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.83, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61903.67, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15123.71, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14162.96, "additional_payer_notes": "107% 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 : 1", "code_information": [ { "code": "1771", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9740.2, "maximum": 10422.01, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10422.01, "additional_payer_notes": "107% 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": "CARDIOMYOPATHY - SOI : 4", "code_information": [ { "code": "2054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15093.7, "maximum": 16150.26, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16150.26, "additional_payer_notes": "107% 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 ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6739, "minimum": 6453.72, "maximum": 13862.555, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13163.39 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6739.79, "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": 6518.26, "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": 12310.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8761.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8424.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12212.5, "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": 9840.09, "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": 9476.14, "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": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6840.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10446.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10446.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10783.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9894.67 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6453.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12310.46 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9884.35, "additional_payer_notes": "107% 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 : 3", "code_information": [ { "code": "1773", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18511.47, "maximum": 19807.27, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19807.27, "additional_payer_notes": "107% 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": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19808, "minimum": 18931.5, "maximum": 35892.2047, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32668.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19808.06, "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": 19120.82, "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": 32036.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 25750.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24760.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35892.2, "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": 28919.77, "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": 27850.13, "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": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19808.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20067.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19808.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 30702.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 30702.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31692.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19808.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28481.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18931.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32036.22 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4061.96, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13054.74, "additional_payer_notes": "107% 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 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": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6057.2, "additional_payer_notes": "107% 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" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7755, "minimum": 6718.35, "maximum": 14052.513, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13454.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7755.25, "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": 7497.54, "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": 12920.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10081.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9694.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14052.51, "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": 11322.67, "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": 10903.88, "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": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7755.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7868.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7755.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12020.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12020.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12408.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7755.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6718.35 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7423.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12920.39 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16458.79, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9226.45, "additional_payer_notes": "107% 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 ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12431, "minimum": 9114.8734, "maximum": 22525.3344, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21719.77 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12431.2, "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": 12006.88, "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": 21074.94 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16160.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15539, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22525.33, "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": 18149.55, "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": 17478.27, "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": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12601.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 19268.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19268.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19889.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12137.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11888, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21074.94 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16143, "minimum": 9553.8002, "maximum": 29252.1851, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27764.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16143.59, "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": 15586.93, "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": 26169.35 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20986.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20179.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29252.19, "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": 23569.64, "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": 22697.89, "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": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16143.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16358.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16143.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25022.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25022.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25829.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16143.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21033.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15432.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26169.35 } ] } ] }, { "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": 50735, "minimum": 48461.3, "maximum": 91932.5086, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83984.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 50735.38, "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": 48945.91, "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": 80262.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 65955.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 63419.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 91932.51, "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": 74073.65, "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": 71333.94, "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": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 50735.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51368.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 50735.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 78639.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 78639.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 81176.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 50735.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 55217.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 48461.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80262.68 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6061, "minimum": 5707.25, "maximum": 10983.9997, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9990.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6061.81, "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": 5864.44, "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": 9778.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 7880.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7577.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10984, "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": 8850.24, "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": 8522.9, "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": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6061.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6154.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6061.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 9395.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9395.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9698.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6061.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5707.25 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5806.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9778.12 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9527, "minimum": 7351.3746, "maximum": 17263.975, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13395.78, "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": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9527.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9662.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9527.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14767.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14767.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15244.13, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9527.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11215.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16190.25 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17029.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9527.58, "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": 9206.7, "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": 16190.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9115.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12385.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11909.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17263.97, "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": 13910.27, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86425.12, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20038.67, "additional_payer_notes": "107% 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 DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 60384, "minimum": 47676.4, "maximum": 112197.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112197.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 60384.82, "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": 58251.35, "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": 108256.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 78500.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 75481.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 109417.29, "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": 88161.84, "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": 84901.06, "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": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 60384.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61135.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 60384.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 93596.47, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 93596.47, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 96615.71, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 60384.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47676.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 57674.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 108256.58 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5736.2, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11551.78, "additional_payer_notes": "107% 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 PACEMAKER DEVICE REPLACEMENT WITHOUT MCC", "code_information": [ { "code": "259", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20599, "minimum": 19687.5, "maximum": 42240.8608, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33723.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20599.87, "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": 19884.38, "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": 30718.49 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26779.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25749.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37326.96, "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": 30075.81, "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": 28963.42, "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": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20599.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20868.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20599.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31929.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31929.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32959.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20599.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24689.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19687.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30718.49 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.1, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4006.37, "additional_payer_notes": "107% 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 DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 71605, "minimum": 68388.6, "maximum": 129749.8546, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 127113.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 71605.88, "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": 69072.49, "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": 123506.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 93087.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 89507.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 129749.85, "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": 104544.58, "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": 100677.87, "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": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 71605.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 72491.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 71605.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 110989.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 110989.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 114569.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 71605.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 82407.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 68388.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 123506.6 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16321.54, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15335.83, "additional_payer_notes": "107% 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": "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": 66063, "minimum": 63096.5, "maximum": 119706.609, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102920.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 66063.25, "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": 63727.47, "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": "case rate", "standard_charge_dollar": 103973.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 85882.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 82579.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 119706.61, "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": 96452.35, "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": 92884.93, "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": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66882.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 102398.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 102398.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 105701.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 83567.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103973.08 } ] } ] }, { "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": 66063, "minimum": 63096.5, "maximum": 119706.609, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114999.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 66063.25, "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": 63727.47, "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": "case rate", "standard_charge_dollar": 112861.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 85882.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 82579.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 119706.61, "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": 96452.35, "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": 92884.93, "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": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66882.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 102398.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 102398.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 105701.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66063.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 66463.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 63096.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112861.64 } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14600, "minimum": 11309.5074, "maximum": 26874.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26874.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14600.92, "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": 14099.2, "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": 25676.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18981.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18251.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26456.87, "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": 21317.34, "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": 20528.89, "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": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14600.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14797.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14600.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22631.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22631.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23361.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14600.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16061.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13959.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25676.51 } ] } ] }, { "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": 53656, "minimum": 51250.8, "maximum": 97226.4296, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94752.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 53656.97, "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": 51763.31, "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": 92567.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 69754.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 67071.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 97226.43, "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": 78339.18, "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": 75441.7, "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": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 53656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54325.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 83168.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 83168.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 85851.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 66329.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 51250.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92567.9 } ] } ] }, { "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": 77076, "minimum": 69251.7408, "maximum": 139662.8536, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 139315.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 77076.63, "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": 74348.32, "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": 135224.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 100199.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 96345.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 139662.85, "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": 112531.88, "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": 108369.74, "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": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 77076.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 78028.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 77076.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 119468.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 119468.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 123322.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 77076.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 96262.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 73612.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 135224.6 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24923, "minimum": 7540, "maximum": 38631.177, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32010.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24923.34, "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": 24053.76, "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": 32193.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32400.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31154.18, "additional_payer_notes": "125.00% 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": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24923.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25244.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24923.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 38631.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 38631.18, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24923.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18420.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23815.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32193.5 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51935.38, "additional_payer_notes": "107% 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 : 1", "code_information": [ { "code": "1621", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38042.75, "maximum": 40705.74, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40705.74, "additional_payer_notes": "107% 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": "CESAREAN SECTION WITH STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9972, "minimum": 7540, "maximum": 15651.17, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12964.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12466.14, "additional_payer_notes": "125.00% 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": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9972.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10113.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9972.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15458.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15458.01, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9972.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9642.85 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15265.74 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15651.17 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9540.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9972.91, "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": 9636.16, "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": 15265.74 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75975.89, "additional_payer_notes": "107% 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" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47375.47, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7254.34, "additional_payer_notes": "107% 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": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 39058, "minimum": 37311.6, "maximum": 70773.1141, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70485.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 39058.01, "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": 37684.72, "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": 67960.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 50775.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 48822.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 70773.11, "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": 57024.69, "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": 54915.56, "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": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 39058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39550.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 60539.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 60539.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 62492.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54623.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37311.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67960.96 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34173.26, "additional_payer_notes": "107% 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": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16879, "minimum": 7540, "maximum": 31607.67, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31607.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16879.48, "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": 16296.55, "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": 28240.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21943.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21099.35, "additional_payer_notes": "125.00% 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": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16879.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17103.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16879.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 26163.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26163.19, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16879.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16135.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28240.32 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39473.88, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9051.77, "additional_payer_notes": "107% 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": "CARDIOMYOPATHY - SOI : 1", "code_information": [ { "code": "2051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4035.8, "maximum": 4318.31, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4318.31, "additional_payer_notes": "107% 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": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26295, "minimum": 16988.2852, "maximum": 47647.0292, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44154.99 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 26295.27, "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": 25376.76, "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": 44631.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 34183.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32869.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47647.03, "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": 38391.09, "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": 36971.15, "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": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 26295.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26633.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26295.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 40757.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 40757.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 42072.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26295.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19733.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25125.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44631.55 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24278, "minimum": 23199.7, "maximum": 43992.3158, "payers_information": [ { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 37631.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38845.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24278.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34788.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39755.6 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41544.35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24278.32, "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": 23431.7, "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": 39755.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 31561.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30347.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43992.32, "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": 35446.35, "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": 34135.32, "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": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24278.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24591.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24278.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23199.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 37631.4, "additional_payer_notes": "155.00% of Medicare Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8272.5, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10139.57, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5767.04, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35981, "minimum": 34374.2, "maximum": 65198.7498, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63688.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 35981.65, "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": 34717.94, "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": 61234.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 46776.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 44977.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 65198.75, "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": 52533.21, "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": 50590.2, "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": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 35981.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36436.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35981.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 55771.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 55771.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 57570.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35981.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 49216.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 34374.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61234.24 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22526.6, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY- SOI : 2", "code_information": [ { "code": "2632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11931.43, "maximum": 12766.63, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12766.63, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17792.74, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7925.4, "additional_payer_notes": "107% 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": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7598, "minimum": 7273.63, "maximum": 13768.4639, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13073.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7598.49, "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": 7346.37, "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": 12467.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9878.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9498.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13768.46, "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": 11093.8, "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": 10683.48, "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": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7598.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7710.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7598.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11777.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11777.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12157.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8293.86 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7273.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12467.75 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13304.28, "additional_payer_notes": "107% 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": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 431586, "minimum": 412103, "maximum": 782034.883, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 665625.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 431586.58, "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": 416224.03, "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": 659088.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 561062.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 539483.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 782034.88, "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": 630116.41, "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": 606810.73, "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": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 431586.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 436829.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 431586.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 668959.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 668959.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 690538.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 431586.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 459647 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 412103, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 659088.65 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7523, "minimum": 7202.12, "maximum": 13632.7632, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12095.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7523.6, "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": 7274.14, "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": 12172.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9780.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9404.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13632.76, "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": 10984.46, "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": 10578.18, "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": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7523.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7634.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7523.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11661.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11661.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12037.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7523.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8412.81 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7202.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12172.4 } ] } ] }, { "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": "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" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5475.3, "additional_payer_notes": "107% of State Medicaid Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8608.26, "additional_payer_notes": "107% 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": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9105, "minimum": 7228.34, "maximum": 19116.6906, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15983.6 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9105.22, "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": 8799.39, "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": 15393.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11836.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11381.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16498.66, "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": 13293.62, "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": 12801.94, "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": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9105.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9235.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9105.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14113.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14113.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14568.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9105.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7228.34 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8712.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15393.32 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 48623, "minimum": 46444.9, "maximum": 88870.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88870.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 48623.57, "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": 46909.35, "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": 84888.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 63210.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 60779.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 88105.91, "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": 70990.41, "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": 68364.74, "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": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 48623.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49231.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 48623.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 75366.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 75366.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 77797.71, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 48623.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 55746.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 46444.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84888.72 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29825, "minimum": 28496.7, "maximum": 54044.6033, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53394.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 29825.94, "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": 28781.67, "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": 50632.99 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 38773.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 37282.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 54044.6, "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": 43545.87, "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": 41935.27, "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": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 29825.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30206.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29825.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 46230.21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 46230.21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47721.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29825.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34893.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 28496.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50632.99 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.8, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21045, "minimum": 20112.7, "maximum": 38133.8843, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35696.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21045.19, "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": 20313.83, "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": "case rate", "standard_charge_dollar": 34570.31 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27358.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26306.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38133.88, "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": 30725.98, "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": 29589.54, "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": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21045.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21319.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21045.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 32620.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32620.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33672.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21045.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28412.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20112.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34570.31 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24785, "minimum": 23684, "maximum": 44911.4166, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44454.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24785.55, "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": 23920.84, "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": 41373.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32221.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30981.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44911.42, "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": 36186.9, "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": 34848.48, "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": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24785.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25105.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24785.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 38417.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 38417.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39656.88, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24785.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29814.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41373.92 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5896.81, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14021, "minimum": 13406.7, "maximum": 28751.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24194.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14021.8, "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": 13540.77, "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": 23946.33 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18228.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17527.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25407.5, "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": 20471.83, "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": 19714.65, "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": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14021.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14211.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14021.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 21733.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 21733.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22434.88, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14021.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28751.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13406.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23946.33 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11994.17, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10014.34, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26040.79, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY- SOI : 4", "code_information": [ { "code": "2634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27036.79, "maximum": 28929.37, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28929.37, "additional_payer_notes": "107% 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": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15639, "minimum": 14951.1, "maximum": 28338.5022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28184.03 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15639.35, "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": 15100.61, "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": 27053.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20331.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19549.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28338.5, "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": 22833.45, "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": 21988.93, "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": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15639.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15848.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15639.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24240.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24240.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25022.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15639.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15832.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14951.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27053.66 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10994, "minimum": 7540, "maximum": 18927.0755, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18502.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10994.36, "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": 10621.16, "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": 18927.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14292.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13742.95, "additional_payer_notes": "125.00% 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": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10994.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11146.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10994.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17041.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17041.26, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10994.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11622 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10516, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18927.08 } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9982, "minimum": 7540, "maximum": 15811.0113, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15447.02 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9982.89, "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": 9645.78, "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": 15811.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12977.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12478.61, "additional_payer_notes": "125.00% 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": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9982.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10123.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9982.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15473.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15473.48, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9982.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12572.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15811.01 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8826, "minimum": 8446.27, "maximum": 15993.8717, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15338.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8826.64, "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": 8530.73, "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": 15014.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11474.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11033.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15993.87, "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": 12886.89, "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": 12410.26, "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": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8826.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8826.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13681.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13681.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14122.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8826.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10166.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8446.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15014.08 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2942.39, "additional_payer_notes": "107% 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": "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": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12688.24, "additional_payer_notes": "107% 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" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6255.7, "additional_payer_notes": "107% 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": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11094, "minimum": 10611.4, "maximum": 35142.7132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19540.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11094.21, "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": 10717.51, "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": 19044.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14422.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13867.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20102.71, "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": 16197.55, "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": 15598.46, "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": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11094.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11248.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11094.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17196.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17196.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17750.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11094.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15338.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10611.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19044.17 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6377.07, "additional_payer_notes": "107% 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": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11560, "minimum": 7540, "maximum": 18989.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18989.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11560.51, "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": 11167.17, "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": 18556.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15028.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14450.64, "additional_payer_notes": "125.00% 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": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11560.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11720, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11560.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17918.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17918.79, "additional_payer_notes": "155.00% 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 Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11560.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17202.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11056.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18556.57 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8890, "minimum": 8507.29, "maximum": 35185.567, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15107.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8890.54, "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": 8592.36, "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": 14311.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11557.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11113.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16109.66, "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": 12980.19, "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": 12500.1, "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": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8890.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9017.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8890.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13780.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13780.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14224.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8890.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9222.71 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14311.53 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 160096.15, "maximum": 160096.15, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 160096.15 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41757.24, "additional_payer_notes": "107% 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": "CHEST PAIN - SOI : 1", "code_information": [ { "code": "2031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4004, "maximum": 4284.28, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4284.28, "additional_payer_notes": "107% 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": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7282, "minimum": 6972.36, "maximum": 22717.7084, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12606.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7282.97, "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": 7042.08, "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": 12018.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9467.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9103.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13196.74, "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": 10633.14, "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": 10239.86, "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": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7282.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7390.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7282.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11288.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11288.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11652.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7282.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7606.71 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6972.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12018.61 } ] } ] }, { "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": 48379, "minimum": 27106.9764, "maximum": 87664.4513, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87515.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 48379.94, "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": 46674.32, "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": 87508.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 62893.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 60474.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 87664.45, "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": 70634.71, "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": 68022.2, "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": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 48379.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48984.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 48379.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 74988.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 74988.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 77407.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 48379.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64385.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 46212.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87508.45 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16147.99, "additional_payer_notes": "107% 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" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15091.58, "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": 11378, "minimum": 10883.1, "maximum": 20774.89, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20774.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11378.78, "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": 10991.93, "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": 18736.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14792.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14223.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20618.35, "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": 16613.02, "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": 15998.56, "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": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11378.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11536.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11378.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17637.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17637.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18206.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11378.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19250.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10883.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18736.58 } ] } ] }, { "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": 21251, "minimum": 18750.4854, "maximum": 38508.4066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36164.09 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21251.88, "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": 20513.1, "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": 35445.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27627.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26564.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38508.41, "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": 31027.74, "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": 29880.14, "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": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21251.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21528.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21251.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 32940.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32940.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34003.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21251.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19676.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20310, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35445.89 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33392, "minimum": 31902.1, "maximum": 60507.3187, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54929.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 33392.56, "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": 32221.12, "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": 47822.76 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 43410.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 41740.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60507.32, "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": 48753.14, "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": 46949.94, "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": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33392.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33816.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33392.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 51758.47, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 51758.47, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53428.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33392.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38437.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31902.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47822.76 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11228, "minimum": 10739.1, "maximum": 20345.1541, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19385.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11228.01, "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": 10846.49, "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": 19033.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14596.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14035.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20345.15, "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": 16392.89, "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": 15786.58, "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": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11228.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11383.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11228.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17403.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17403.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17964.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11228.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12705.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19033.68 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7401.35, "additional_payer_notes": "107% 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": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14826, "minimum": 13015.3, "maximum": 42008.4114, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23542.7 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14826.58, "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": 14316.85, "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": 23949.83 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19274.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18533.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26865.76, "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": 21646.81, "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": 20846.17, "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": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14826.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15025.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14826.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22981.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22981.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23722.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14826.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13015.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23949.83 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9964.89, "additional_payer_notes": "107% 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": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20001, "minimum": 18944, "maximum": 36243.2072, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36243.21, "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": 29202.58, "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": 28122.49, "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": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20001.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20263.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20001.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31002.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31002.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32002.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20001.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18944 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33630.08 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35202.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20001.77, "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": 19307.56, "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": 33630.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19116.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26002.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25002.21, "additional_payer_notes": "125.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5927.89, "additional_payer_notes": "107% 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": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13471, "minimum": 11030.3084, "maximum": 24410.5936, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21907.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13471.63, "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": 13010.21, "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": 22207.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17513.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16839.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24410.59, "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": 19668.58, "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": 18941.11, "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": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13471.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13654.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13471.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20881.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20881.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21554.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13471.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11436 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22207.42 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17464.93, "additional_payer_notes": "107% 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": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 108986, "minimum": 104080, "maximum": 197483.4836, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 194590.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 108986.47, "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": 105120.8, "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": 190387.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 141682.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 136233.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 197483.48, "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": 159120.25, "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": 153234.98, "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": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 108986.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 110324.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 108986.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 168929.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 168929.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 174378.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 108986.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 153023 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 104080, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 190387.5 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11925, "minimum": 10858.8932, "maximum": 21667.38, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21667.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11925.96, "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": 11519.56, "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": 20232.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15503.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14907.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21609.84, "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": 17411.9, "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": 16767.9, "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": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11925.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12089.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11925.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18485.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18485.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19081.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11925.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15904.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11405.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20232.57 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5120.26, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5273.39, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10491.2, "additional_payer_notes": "107% 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": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8758, "minimum": 8381.45, "maximum": 25074.6674, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14874.3 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8758.74, "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": 8465.26, "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": 13040.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11386.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10948.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15870.84, "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": 12787.76, "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": 12314.79, "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": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8758.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8884.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8758.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13576.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13576.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14013.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10226.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8381.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13040.98 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6438.33, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23431.38, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.95, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7701.95, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16488.28, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50216.91, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20524.15, "additional_payer_notes": "107% 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": "Cor Hlx Vlgs Rsc Prx Phlx Bs", "code_information": [ { "code": "28292", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13125, "discounted_cash": 4187, "minimum": 423.48, "maximum": 13125, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 453.12 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 423.48 }, { "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 Health Plan", "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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68115.13, "additional_payer_notes": "107% 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": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21402, "minimum": 20454, "maximum": 38781.6199, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37327.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21402.66, "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": 20658.54, "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": 37252.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27823.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26753.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38781.62, "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": 31247.88, "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": 30092.14, "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": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21402.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21402.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 33174.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 33174.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34244.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21402.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29942.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20454, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37252.96 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6504.11, "additional_payer_notes": "107% 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": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 84581, "minimum": 74969.9, "maximum": 153261.3156, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 146614.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 84581.3, "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": 81585.48, "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": 148094.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 109955.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 105726.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 153261.32, "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": 123488.7, "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": 118921.31, "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": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 84581.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 85624.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 84581.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 131101.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 131101.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 135330.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 84581.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 74969.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 80777.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 148094.32 } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 76746, "minimum": 70938.6222, "maximum": 140912.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 140912.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 76746.13, "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": 74029.57, "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": 136603.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 99769.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 95932.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 139063.99, "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": 112049.35, "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": 107905.06, "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": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 76746.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 77694.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 76746.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 118956.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 118956.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 122793.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 76746.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 99307.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 73296.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 136603.5 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16989, "minimum": 16240.1, "maximum": 30784.6478, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30784.65, "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": 24804.41, "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": 23886.98, "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": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16989.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17214.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16989.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 26333.45, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26333.45, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27182.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16989.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23352.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29054.72 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27273.47 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16989.32, "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": 16402.5, "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": 29054.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16240.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22086.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21236.65, "additional_payer_notes": "125.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31852.48, "additional_payer_notes": "107% 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": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 60943, "minimum": 58208.5, "maximum": 110430.4918, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107471.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 60943.98, "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": 58790.59, "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": 106758.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 79227.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 76179.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 110430.49, "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": 88978.21, "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": 85687.24, "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": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 60943.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61701.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 60943.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 94463.17, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 94463.17, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 97510.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 60943.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 85807.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 58208.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106758.84 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4122.07, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.07, "additional_payer_notes": "107% 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": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31454, "minimum": 30051.6, "maximum": 56995.5178, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53352.74 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 31454.48, "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": 30352.12, "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": 53453.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 40890.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39318.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56995.52, "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": 45923.54, "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": 44225, "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": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 31454.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31854.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31454.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 48754.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 48754.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50327.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31454.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35941.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30051.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53453.7 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58900.02, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.71, "additional_payer_notes": "107% 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": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 67618, "minimum": 48866.318, "maximum": 126672, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110029.75 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 67618.9, "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": 65227.62, "additional_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": 119334.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 87904.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 84523.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 122525.45, "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": 98723.59, "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": 95072.17, "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": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 67618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68456.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 67618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 104809.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 104809.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 108190.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 67618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 126672 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 64581.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 119334.95 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15580.84, "additional_payer_notes": "107% 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": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 110501.29, "maximum": 110501.29, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110501.29 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60978.08, "additional_payer_notes": "107% 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": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10701, "minimum": 10236.7, "maximum": 19391.6797, "payers_information": [ { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10701.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11857.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18217.53 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18540.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10701.81, "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": 10339.07, "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": 18217.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13912.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13377.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19391.68, "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": 15624.64, "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": 15046.74, "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": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10701.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10850.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10701.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10236.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16587.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16587.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17122.9, "additional_payer_notes": "160.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4926.29, "additional_payer_notes": "107% 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": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 83207.94, "maximum": 83207.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83207.94 } ] } ] }, { "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": 57625, "minimum": 55040.5, "maximum": 104418.2758, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102416.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 57625.98, "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": 55590.91, "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": 99705.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 74913.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 72032.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104418.28, "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": 84133.93, "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": 81022.13, "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": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 57625.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58342.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57625.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 89320.27, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 89320.27, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 92201.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57625.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80097.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 55040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99705.32 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36109.53, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5915.41, "additional_payer_notes": "107% 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": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10417, "minimum": 8939.5624, "maximum": 18876.0389, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18677.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10417.24, "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": 10064.65, "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": 17754.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13542.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13021.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18876.04, "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": 15209.17, "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": 14646.64, "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": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10417.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10562.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10417.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16146.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16146.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16667.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10417.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10451.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9965, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17754.4 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6997.54, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8637.75, "additional_payer_notes": "107% 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": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11469, "minimum": 10969.9, "maximum": 20783.0058, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19909.49 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11469.65, "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": 11079.6, "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": 19626.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14910.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14337.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20783.01, "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": 16745.69, "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": 16126.33, "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": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11469.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11628.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11469.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17777.96, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17777.96, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18351.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11469.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11427.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10969.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19626.14 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18689, "minimum": 13015.8678, "maximum": 33865.827, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32966.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18689.75, "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": 18042.34, "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": 31870.19 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24296.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23362.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33865.83, "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": 27287.04, "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": 26277.79, "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": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18689.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18935.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18689.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 28969.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 28969.11, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29903.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18689.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18044.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17863.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31870.19 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18125.09, "additional_payer_notes": "107% 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": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6819, "minimum": 6336.18, "maximum": 12357.242, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11595.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6819.67, "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": 6595.29, "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": 11310.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8865.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8524.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12357.24, "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": 9956.72, "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": 9588.46, "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": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6819.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6921.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6819.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10570.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10570.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10911.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6819.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6336.18 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6529.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11310.81 } ] } ] }, { "description": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8628, "minimum": 8257.51, "maximum": 16888.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16888.74 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8628.93, "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": 8340.09, "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": 14982.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11217.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10786.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15635.62, "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": 12598.24, "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": 12132.28, "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": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8628.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8752.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8628.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13374.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13374.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13806.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8628.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15770.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14982.62 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22503, "minimum": 13896.3186, "maximum": 40777.2299, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38944.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22503.99, "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": 21720.66, "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": 38680.79 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 29255.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28129.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40777.23, "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": 32855.83, "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": 31640.61, "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": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22503.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22795.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22503.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 34881.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 34881.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36006.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22503.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25795.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21505.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38680.79 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4760.69, "additional_payer_notes": "107% 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": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10955, "minimum": 10478.9, "maximum": 19851.221, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18626.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10955.42, "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": 10583.69, "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": 18696.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14242.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13694.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19851.22, "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": 15994.91, "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": 15403.32, "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": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10955.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11107.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10955.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16980.9, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16980.9, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17528.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10955.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12772.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10478.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18696.39 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17798.41, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35709.12, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18794.34, "additional_payer_notes": "107% 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": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20061, "minimum": 19173.6, "maximum": 36351.7642, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34615.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20061.68, "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": 19365.34, "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": 34238.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26080.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25077.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36351.76, "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": 29290.05, "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": 28206.72, "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": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20061.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20324.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20061.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31095.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31095.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32098.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20061.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25068.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19173.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34238.26 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.73, "additional_payer_notes": "107% 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": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13345, "minimum": 12761.2, "maximum": 24628.51, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13345.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13526.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13345.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20686.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20686.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21353.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13345.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20447.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23320.67 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24628.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13345.82, "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": 12888.81, "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": 23320.67 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12761.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17349.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16682.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24182.63, "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": 19484.9, "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": 18764.22, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "Cystoscopy And Treatment", "code_information": [ { "code": "52240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15375, "discounted_cash": 6862, "minimum": 961.25, "maximum": 15375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "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": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "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": 9648.49, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1028.54 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10636.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10636.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11349.88, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6569.91, "additional_payer_notes": "107% 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": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7483, "minimum": 7163.99, "maximum": 24857.8012, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12198.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7483.66, "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": 7235.63, "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": 11527.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9728.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9354.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13560.39, "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": 10926.14, "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": 10522.03, "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": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7483.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7593.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7483.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11599.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11599.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11973.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7483.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7375.13 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7163.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11527.52 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37673.74, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.56, "additional_payer_notes": "107% 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": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5909.9286, "maximum": 14400.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14400.96 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13802.96 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11094.3 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13802.96 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8254.35, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41266.09, "additional_payer_notes": "107% 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": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9804, "minimum": 5805.96, "maximum": 17765.1379, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16377.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9804.16, "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": 9473.43, "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": 15975.29 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12745.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12255.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17765.14, "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": 14314.07, "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": 13784.65, "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": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9804.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9942.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9804.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15196.45, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15196.45, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15686.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9804.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5805.96 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9379.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15975.29 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43439.42, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20648.92, "additional_payer_notes": "107% 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": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54954, "minimum": 52489.3, "maximum": 99576.6842, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 85178.73, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 85178.73, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 87926.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 54954.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 81451.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92978.6 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93908.84 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 54954.02, "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": 53014.19, "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": 92978.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 71440.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 68692.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 99576.68, "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": 80232.87, "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": 77265.35, "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": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 54954.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55638.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52489.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 54954.02, "additional_payer_notes": "100.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10708.99, "additional_payer_notes": "107% 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": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8403, "minimum": 7502.94, "maximum": 15226.7252, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13678.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8403.27, "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": 8122.46, "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": "case rate", "standard_charge_dollar": 13095.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10924.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10504.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15226.73, "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": 12268.77, "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": 11815, "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": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8403.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8524.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8403.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13025.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13025.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13445.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8403.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7502.94 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8042.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.16 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42234, "minimum": 40344.2, "maximum": 76528.3885, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73011.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 42234.21, "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": 40747.64, "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": 71865.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 54904.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 52792.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76528.39, "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": 61661.95, "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": 59381.3, "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": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 42234.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42764.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42234.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 65463.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 65463.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 67574.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42234.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61850.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40344.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71865.21 } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13906, "minimum": 13297, "maximum": 27710.69, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27710.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13906.97, "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": 13429.97, "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": 24654.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18079.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17383.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25199.43, "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": 20304.18, "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": 19553.2, "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": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13906.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14094.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13906.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 21555.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 21555.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22251.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13906.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19815.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13297, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24654.13 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42758.84, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12232.37, "additional_payer_notes": "107% 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": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16428, "minimum": 15704.3, "maximum": 29767.8259, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27334.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16428.16, "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": 15861.34, "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": 27011.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21356.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20535.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29767.83, "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": 23985.11, "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": 23097.99, "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": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16428.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16646.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16428.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25463.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25463.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26285.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16428.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19042.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27011.72 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25188, "minimum": 14978.0524, "maximum": 45642.3593, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44161.43 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45043.87 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 25188.94, "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": 24309.89, "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": 44161.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32745.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31486.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45642.36, "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": 36775.85, "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": 35415.65, "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": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25188.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25513.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25188.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 39042.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 39042.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40302.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25188.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30673.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24069.2, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45807, "minimum": 43756.3, "maximum": 83003.7698, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79782.5 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 45807.82, "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": 44193.86, "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": "case rate", "standard_charge_dollar": 78160.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 59550.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 57259.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83003.77, "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": 66879.42, "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": 64405.79, "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": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 45807.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46381.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45807.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 71002.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 71002.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 73292.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45807.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54065.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43756.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78160.26 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15325.62, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9554.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24176.62, "additional_payer_notes": "107% 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": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6611, "minimum": 5803.42, "maximum": 17344.1016, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11246.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6611.98, "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": 6395.01, "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": 10950.79 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8595.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8264.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11980.91, "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": 9653.49, "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": 9296.44, "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": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6611.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6711.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6611.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10248.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10248.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10579.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6611.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5803.42 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6331.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10950.79 } ] } ] }, { "description": "Cor Hlx Vlgs Dstl Mtar Osteo", "code_information": [ { "code": "28296", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28875, "discounted_cash": 4187, "minimum": 574.61, "maximum": 28875, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.83 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 574.61 }, { "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 Health Plan", "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": "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": 39469, "minimum": 37704.3, "maximum": 71518.5347, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68451.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 39469.39, "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": 38081.34, "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": 66440.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 51310.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 49336.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 71518.53, "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": 57625.31, "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": 55493.96, "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": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 39469.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39966.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39469.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 61177.55, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 61177.55, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 63151.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39469.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 49330.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37704.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66440.5 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8331.48, "additional_payer_notes": "107% 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 WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59006, "minimum": 54395.7568, "maximum": 106920.5028, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106242.97 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 59006.9, "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": 56922.59, "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": 102835.36 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 76708.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 73758.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 106920.5, "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": 86150.07, "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": 82963.7, "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": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 59006.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 59740.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59006.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 91460.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 91460.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 94411.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59006.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 76527.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56359, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102835.36 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7715.56, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10881.41, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35377.9, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11559.72, "additional_payer_notes": "107% 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": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43618, "minimum": 41665.6, "maximum": 79036.0516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74796.09 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 43618.13, "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": 42082.26, "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": 74439.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 56703.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 54522.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 79036.05, "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": 63682.47, "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": 61327.09, "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": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43618.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44165.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43618.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 67608.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 67608.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69789.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43618.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 66930.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 41665.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74439.51 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13719.44, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6599.4, "additional_payer_notes": "107% 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": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31871, "minimum": 30450.1, "maximum": 64766.3764, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53632.77 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 31871.85, "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": 30754.6, "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": 55839.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 41433.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39839.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57751.79, "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": 46532.9, "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": 44811.82, "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": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 31871.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32277.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31871.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 49401.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 49401.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50994.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31871.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50451.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30450.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55839.24 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23482.42, "additional_payer_notes": "107% 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": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32464, "minimum": 31016.4, "maximum": 58826.5075, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47773.74 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 32464.96, "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": 31326.56, "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": 50019.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 42204.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 40581.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 58826.51, "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": 47398.84, "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": 45645.73, "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": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32464.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32877.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32464.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 50320.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 50320.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51943.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32464.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 40202.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31016.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50019.56 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13409.78, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5636.37, "additional_payer_notes": "107% 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": "Cysto/Uretero W/Lithotripsy", "code_information": [ { "code": "52356", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12937.5, "discounted_cash": 6862, "minimum": 354.06, "maximum": 12937.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "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": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "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": 9648.49, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 378.84 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10636.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10636.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare 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": "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" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7909.53, "additional_payer_notes": "107% 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": 25600, "minimum": 24462, "maximum": 46387.7798, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43954.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 25600.32, "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": 24706.62, "additional_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": 43128.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 33280.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32000.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46387.78, "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": 37376.47, "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": 35994.05, "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": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25600.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25929.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25600.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 39680.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 39680.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40960.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25600.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35882.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24462, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43128.57 } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20869, "minimum": 14771.575, "maximum": 37815.4615, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34008.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20869.46, "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": 20144.35, "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": 34149.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 27130.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26086.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37815.46, "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": 30469.41, "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": 29342.46, "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": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20869.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21141.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20869.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 32347.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32347.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33391.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20869.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19290.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19944.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34149.13 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10043.16, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18253.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24235.61, "additional_payer_notes": "107% 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": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8808, "minimum": 8429.11, "maximum": 15961.2919, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15450.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8808.66, "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": 8513.4, "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": 15033.31 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11451.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11010.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15961.29, "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": 12860.64, "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": 12384.98, "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": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8808.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8934.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8808.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13653.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13653.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14093.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8808.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9644.11 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8429.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15033.31 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21405.51, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7596.45, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30075.01, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3014.99, "additional_payer_notes": "107% 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": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16686, "minimum": 15951.2, "maximum": 30236.4272, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30149.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16686.77, "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": 16110.71, "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": 29075.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21692.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20858.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30236.43, "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": 24362.68, "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": 23461.6, "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": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16686.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16908.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16686.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25864.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25864.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26698.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16686.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20660 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15951.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29075.69 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20198.6, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58842.18, "additional_payer_notes": "107% 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": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11336, "minimum": 10843, "maximum": 20542.3722, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10951.43, "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": 18953.29 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 14737.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14171.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20542.37, "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": 16551.8, "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": 15939.61, "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": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11336.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11493.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11336.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 17572.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17572.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18138.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11336.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11117.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18953.29 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19634.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10843, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11336.85, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3928.11, "additional_payer_notes": "107% 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": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11767, "minimum": 5504.77, "maximum": 22557.9806, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18715.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11767.2, "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": 11366.54, "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": 17909.94 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15297.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14709, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21322.17, "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": 17180.11, "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": 16544.68, "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": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11767.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11929.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11767.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18239.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18239.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18827.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11767.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5504.77 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11254, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17909.94 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7940.15, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4664.27, "additional_payer_notes": "107% 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": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17093, "minimum": 16339.3, "maximum": 30972.8059, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29506.52 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17093.16, "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": 16502.69, "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": 29437.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22221.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21366.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30972.81, "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": 24956.01, "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": 24032.98, "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": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17093.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17319.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17093.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 26494.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26494.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27349.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17093.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16945.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16339.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29437.46 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23605, "minimum": 22557.2, "maximum": 43762.9637, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43251.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23605.33, "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": 22782.77, "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": 43762.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 30686.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 29506.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42772.86, "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": 34463.78, "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": 33189.09, "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": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23605.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23910.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23605.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 36588.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 36588.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37768.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23605.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30619.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22557.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43762.96 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.15, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6239.82, "additional_payer_notes": "107% 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": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8233.124, "maximum": 21461.1715, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19759.54 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21461.17 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17249.5 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21461.17 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3519.75, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6320.36, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16922.72, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22540.95, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19709.72, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34882.21, "additional_payer_notes": "107% 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": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9493, "minimum": 9083.13, "maximum": 32776.664, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16955.59 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9493.63, "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": 9173.96, "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": "case rate", "standard_charge_dollar": 16438.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12341.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11867.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17202.46, "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": 13860.7, "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": 13348.04, "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": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9493.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9628.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9493.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14715.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14715.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15189.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9493.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10385.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16438.42 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21551, "minimum": 9760.2776, "maximum": 40092.8937, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38138.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21551.43, "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": 20802.06, "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": 40092.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28016.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26939.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39051.19, "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": 31465.09, "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": 30301.31, "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": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21551.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21831.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21551.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 33404.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 33404.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34482.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21551.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18037.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20596.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40092.89 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39534.01, "additional_payer_notes": "107% 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": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17551, "minimum": 16776.8, "maximum": 58200.6548, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30839.84 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17551.47, "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": 16944.57, "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": 28617.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22816.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21939.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31803.26, "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": 25625.15, "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": 24677.37, "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": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17551.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17783.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17551.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 27204.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27204.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28082.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17551.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20453.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16776.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28617.81 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6861.42, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 79229.07, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7411.56, "additional_payer_notes": "107% 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": "DIABETES - SOI : 2", "code_information": [ { "code": "4202", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5392.73, "maximum": 5770.22, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.22, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6606.2, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5865.5, "additional_payer_notes": "107% 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": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9357, "minimum": 8014.19, "maximum": 16956.388, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16249.18 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9357.83, "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": 9043, "additional_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": 16029.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12165.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11697.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16956.39, "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": 13662.43, "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": 13157.11, "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": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9357.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9490.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9357.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14504.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14504.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14972.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9357.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8014.19 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8953.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16029.47 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8995.05, "additional_payer_notes": "107% 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": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13105, "minimum": 12531.5, "maximum": 23746.5862, "payers_information": [ { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17036.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16381.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23746.59, "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": 19133.56, "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": 18425.88, "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": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13105.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13283.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13105.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20313.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20313.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20968.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13105.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15391.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21754.78 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22326.81 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13105.18, "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": 12656.82, "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": 21754.78 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14754, "minimum": 11638.0532, "maximum": 26735.4983, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26184.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14754.69, "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": 14247.57, "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": 25451.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19181.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18443.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26735.5, "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": 21541.85, "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": 20745.09, "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": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14754.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14952.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14754.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22869.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22869.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23607.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14754.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13532.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14106.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25451.06 } ] } ] }, { "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": 212341, "minimum": 202765, "maximum": 385187.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 385187.22 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 212341.48, "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": 204792.65, "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": 374549.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 276043.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 265426.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 384762.76, "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": 310018.56, "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": 298552.12, "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": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 212341.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 214930.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 212341.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 329129.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 329129.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 339746.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 212341.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 327178 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 202765, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 374549.87 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18711.53, "additional_payer_notes": "107% 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 - SOI : 4", "code_information": [ { "code": "2404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15872.88, "maximum": 16983.98, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16983.98, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21026.64, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.03, "additional_payer_notes": "107% 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": "DIABETES - SOI : 1", "code_information": [ { "code": "4201", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4059.12, "maximum": 4343.26, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4343.26, "additional_payer_notes": "107% 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": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9638, "minimum": 9221.37, "maximum": 17464.7989, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16104.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9638.41, "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": 9313.58, "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": 15431.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12529.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12048.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17464.8, "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": 14072.08, "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": 13551.6, "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": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9638.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9774.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9638.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14939.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14939.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15421.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9638.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11241.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9221.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15431.77 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27742.89, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31364.73, "additional_payer_notes": "107% 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": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16845, "minimum": 13310.65, "maximum": 30524.1004, "payers_information": [ { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26952.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16845.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18761.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28963.84 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29721.51 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16845.53, "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": 16263.83, "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": "case rate", "standard_charge_dollar": 28963.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21899.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21056.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30524.1, "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": 24594.47, "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": 23684.82, "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": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16845.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17068.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16845.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16102.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 26110.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26110.57, "additional_payer_notes": "155.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13868.03, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10684.04, "additional_payer_notes": "107% 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": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8080, "minimum": 6517.15, "maximum": 61052.3804, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13746.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8080.76, "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": 7811.44, "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": 13608.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10504.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10100.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14642.34, "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": 11797.91, "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": 11361.55, "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": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8080.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8198.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8080.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12525.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12525.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12929.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6517.15 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7734.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13608.97 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19910.5, "additional_payer_notes": "107% 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 LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10047, "minimum": 9612.25, "maximum": 18206.5955, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17190.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10047.79, "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": 9708.37, "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": 16885.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13062.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12559.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18206.6, "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": 14669.77, "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": 14127.19, "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": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10047.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10188.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10047.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15574.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15574.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16076.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10047.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11801.7 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9612.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16885.82 } ] } ] }, { "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": 18329, "minimum": 17519.5, "maximum": 33212.6735, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33029.52 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18329.29, "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": 17694.7, "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": 33037.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23828.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22911.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33212.67, "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": 26760.76, "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": 25770.98, "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": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18329.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18570.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18329.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 28410.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 28410.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29326.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18329.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22885.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17519.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33037.62 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10643, "minimum": 9977.1438, "maximum": 19286.7287, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19181.4 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10643.89, "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": 10283.21, "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": 18060.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13837.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13304.86, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19286.73, "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": 15540.08, "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": 14965.31, "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": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10643.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10792.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10643.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16498.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16498.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17030.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10643.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10388.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10181.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18060.24 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.53, "additional_payer_notes": "107% 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": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "443", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7395, "minimum": 7080.09, "maximum": 13401.1896, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7395.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7600.39 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12280.75 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12912.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7395.8, "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": 7150.89, "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": 12280.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 9614.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9244.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13401.19, "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": 10797.87, "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": 10398.49, "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": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7395.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7504.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7395.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11463.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11463.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11833.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7080.09, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12487, "minimum": 11941.3, "maximum": 22626.6433, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21649.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12487.11, "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": 12060.71, "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": 21473.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16233.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15608.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22626.64, "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": 18231.18, "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": 17556.88, "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": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12487.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12657.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12487.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 19355.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19355.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19979.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12487.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14522.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11941.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21473.41 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6417.91, "additional_payer_notes": "107% 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": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21764, "minimum": 20799.1, "maximum": 39436.5673, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37921.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21764.11, "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": 21007.09, "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": 36899.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 28293.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27205.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39436.57, "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": 31775.6, "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": 30600.34, "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": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21764.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22047.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21764.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 33734.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 33734.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34822.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21764.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27496 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20799.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36899.93 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6613, "minimum": 6333.6, "maximum": 11984.5318, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11121.85 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6613.98, "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": 6396.94, "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": 10749.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8598.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8267.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11984.53, "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": 9656.41, "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": 9299.26, "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": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6713.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10251.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10251.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10582.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6613.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7248.59 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10749.81 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9118.69, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8152.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55982.59, "additional_payer_notes": "107% 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": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20042, "minimum": 12296, "maximum": 36317.3905, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33882.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20042.71, "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": 19347.06, "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": 32399.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26055.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25053.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36317.39, "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": 29262.36, "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": 28180.05, "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": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20042.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20304.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20042.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31066.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31066.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32068.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20042.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15513.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19155.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32399.73 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16636.88, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16765.06, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31288.73, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4804.92, "additional_payer_notes": "107% 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 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": 213592, "minimum": 93144.6822, "maximum": 476214.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 476214.42 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 213592.59, "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": 205998.59, "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": 414592.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 277670.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 266990.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 387029.77, "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": 311845.18, "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": 300311.18, "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": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 213592.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 216196.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 213592.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 331068.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 331068.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 341748.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 213592.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 333226 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 203959, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 414592.08 } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8193, "minimum": 7841.84, "maximum": 14846.7851, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14193.19 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8193.59, "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": 7920.26, "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": 13636.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10651.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10241.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14846.79, "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": 11962.64, "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": 11520.19, "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": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8193.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8312.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8193.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12700.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12700.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13109.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8193.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8160.98 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7841.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13636.93 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35645.59, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30129.47, "additional_payer_notes": "107% 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": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24957, "minimum": 22258.004, "maximum": 45222.6095, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44913.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24957.29, "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": 24086.48, "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": 42787.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 32444.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31196.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45222.61, "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": 36437.64, "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": 35089.95, "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": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24957.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25278.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24957.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 38683.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 38683.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39931.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24957.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30080.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23848, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42787.77 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8669, "minimum": 8296.59, "maximum": 15709.8044, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14480.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8669.87, "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": 8379.56, "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": 13934.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11270.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10837.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15709.8, "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": 12658.01, "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": 12189.84, "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": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8669.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8794.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8669.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13438.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13438.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13871.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8476.09 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8296.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13934.03 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41598.44, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24021.22, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16073.13, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58236.45, "additional_payer_notes": "107% 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 : 4", "code_information": [ { "code": "8434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16967.96, "maximum": 18155.72, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18155.72, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 185129.11, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52892.73, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2306.04, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42501.35, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20197.47, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11768.44, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46323.96, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27879, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3615.04, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11002.78, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52309.7, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6356.66, "additional_payer_notes": "107% 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": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7914, "minimum": 7574.89, "maximum": 15352.0492, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13454.26 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7914.01, "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": 7650.64, "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": 13063.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10288.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9892.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14340.19, "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": 11554.45, "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": 11127.1, "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": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7914.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8029.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7914.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12266.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12266.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12662.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7914.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9718.77 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7574.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13063.7 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25628.53, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8689.93, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57464, "additional_payer_notes": "107% 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": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8368, "minimum": 8008.68, "maximum": 16073.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16073.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8368.33, "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": 8088.77, "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": 13993.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10878.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10460.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15163.41, "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": 12217.76, "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": 11765.87, "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": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8368.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8489.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8368.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12970.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12970.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13389.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8368.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11247.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13993.45 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14781.15, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15013.68, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 208263.3, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7421.77, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13060.41, "additional_payer_notes": "107% 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": "EXTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "038", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16610, "minimum": 15878.8, "maximum": 30098.9327, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28159.92 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28904.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16610.89, "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": 16037.59, "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": 28159.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 21594.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20763.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30098.93, "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": 24251.9, "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": 23354.91, "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": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16610.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16831.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16610.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 25746.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25746.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26577.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16610.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25356.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15878.8, "additional_payer_notes": "100.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13959.92, "additional_payer_notes": "107% 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": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 61600, "minimum": 53155.9, "maximum": 112846.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112846.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 61600.99, "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": 59424.16, "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": 104698.36 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 80081.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 77001.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 111620.99, "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": 89937.45, "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": 86610.99, "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": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 61600.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62365.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 61600.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 95481.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 95481.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 98561.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 61600.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53155.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 58835.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 104698.36 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4440.81, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6176.3, "additional_payer_notes": "107% 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": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47945, "minimum": 5121.33, "maximum": 89316.4094, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88169.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 47945.59, "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": 46255.48, "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": 82221.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 62329.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 59931.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 86877.41, "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": 70000.56, "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": 67411.5, "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": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 47945.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48545.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47945.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 74315.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 74315.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 76712.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47945.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5121.33 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45797.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 82221.8 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5804.25, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11961.26, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10299.51, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15145.27, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15437.92, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9067.65, "additional_payer_notes": "107% 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": "EPISTAXIS WITH MCC", "code_information": [ { "code": "150", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13704, "minimum": 9586.2652, "maximum": 24832.1372, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23748.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13704.27, "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": 13234.54, "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": 24156.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17815.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17130.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24832.14, "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": 20008.23, "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": 19268.2, "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": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13704.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13889.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13704.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 21241.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 21241.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21926.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13704.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19414.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24156.05 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8500.5, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6839.87, "additional_payer_notes": "107% 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": "EPISTAXIS WITHOUT MCC", "code_information": [ { "code": "151", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7738, "minimum": 6302.02, "maximum": 20303.611, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13924 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7738.28, "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": 7481.17, "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": 13247.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10059.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9672.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14021.76, "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": 11297.89, "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": 10880.02, "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": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7738.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7738.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 11994.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11994.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12381.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7738.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6302.02 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7407.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13247.21 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30186.18, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16355.57, "additional_payer_notes": "107% 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": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13073, "minimum": 12501, "maximum": 23688.6928, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23047.67 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13073.23, "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": 12626.01, "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": 22448.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 16995.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16341.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23688.69, "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": 19086.92, "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": 18380.96, "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": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13073.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13251.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13073.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20263.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20263.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20917.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13073.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13106.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12501, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22448.6 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9542.92, "additional_payer_notes": "107% 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": "Exc Back Les Sc 3 Cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 2113, "minimum": 386.08, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 413.11 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Excision Of Anal Lesion(S)", "code_information": [ { "code": "46922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3552, "minimum": 136.71, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "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": 5328.71, "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": 3587.99, "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": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "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": 4994.77, "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": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 5506.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5506.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11339.67, "additional_payer_notes": "107% 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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58548.39, "additional_payer_notes": "107% 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": "Exc feenl mal+mrg 2.1-3", "code_information": [ { "code": "11643", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7175, "discounted_cash": 2113, "minimum": 331.1, "maximum": 7175, "payers_information": [ { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 331.1 }, { "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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 331.1 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 331.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% 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" } ] }, { "setting": "outpatient", "gross_charge": 7175, "discounted_cash": 2113, "minimum": 331.1, "maximum": 7175, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 331.1 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 331.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3276.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 331.1 }, { "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 Health Plan", "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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16395.28, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4367.09, "additional_payer_notes": "107% 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 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": 39292, "minimum": 28706.8516, "maximum": 75619.1717, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54778.2 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 39292.65, "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": 37910.96, "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": "case rate", "standard_charge_dollar": 75619.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 51080.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 49115.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 71198.28, "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": 57367.27, "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": 55245.47, "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": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 39292.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39787.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39292.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 60903.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 60903.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 62868.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39292.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 60779 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 37535.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75619.17 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29224.29, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27562.53, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5578.52, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13285, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17908.44, "additional_payer_notes": "107% 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": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19073, "minimum": 18229.8, "maximum": 34560.584, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31202.98 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19073.17, "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": 18412.1, "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": 30671.3 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24795.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23841.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34560.58, "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": 27846.83, "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": 26816.88, "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": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19073.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19323.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19073.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 29563.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29563.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30517.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19073.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24086.9 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18229.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30671.3 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5872.31, "additional_payer_notes": "107% 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": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "983", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17523, "minimum": 16071.4, "maximum": 44521.2024, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29542.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17523.51, "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": 16917.7, "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": 29154.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 22780.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21904.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31752.6, "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": 25584.32, "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": 24638.06, "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": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17523.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17755.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17523.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 27161.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27161.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28037.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17523.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16071.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16750.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29154.34 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47876.83, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7963.97, "additional_payer_notes": "107% 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": "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": 14635, "minimum": 11628.963, "maximum": 27474.01, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 20578.03, "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": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14635.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14832.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14635.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22685.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22685.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23417.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14635.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16467.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25576.89 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27474.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14635.87, "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": 14132.93, "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": 25576.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13993, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19026.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18294.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26520.2, "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": 21368.37, "additional_payer_notes": "146.00% of Medicare 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16380.52, "additional_payer_notes": "107% 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": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC", "code_information": [ { "code": "981", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47256, "minimum": 31926.081, "maximum": 85643.33, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85643.33 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 47256.63, "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": 45591.1, "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": 83081.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 61433.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 59070.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85629.01, "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": 68994.68, "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": 66442.82, "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": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 47256.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47848.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47256.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 73247.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 73247.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75610.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47256.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70838.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45139.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83081.65 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11897.75, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16133.25, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12506.87, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12858.5, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% 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": "FRACTURES OF HIP AND PELVIS WITH MCC", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13210, "minimum": 10487.4936, "maximum": 23936.5562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23427.07 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13210.02, "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": 12757.92, "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": "case rate", "standard_charge_dollar": 23242.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 17173.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16512.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23936.56, "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": 19286.63, "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": 18573.29, "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": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13210.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13389.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13210.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 20475.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20475.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21136.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13210.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18680.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12631.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23242.03 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 64653.23, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41460.06, "additional_payer_notes": "107% 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": "FRACTURES OF HIP AND PELVIS WITHOUT MCC", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8473, "minimum": 8064.81, "maximum": 15353.384, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14220.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8473.17, "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": 8189.87, "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": 14171.71 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 11015.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10591.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15353.38, "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": 12370.83, "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": 11913.28, "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": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8473.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8595.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8473.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13133.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13133.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13557.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8473.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8064.81 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8108.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14171.71 } ] } ] }, { "description": "Fth gr fr fccmnaxghf", "code_information": [ { "code": "15240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3587.5, "discounted_cash": 2640, "minimum": 483.82, "maximum": 3587.5, "payers_information": [ { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "fee schedule", "standard_charge_dollar": 3587.5, "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": 2667.13, "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": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "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": 3587.5, "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": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "155.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 3587.5, "discounted_cash": 2640, "minimum": 483.82, "maximum": 3587.5, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "fee schedule", "standard_charge_dollar": 3587.5, "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": 2667.13, "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": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "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": 3587.5, "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": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3587.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "EXTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "037", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33280, "minimum": 31795.3, "maximum": 60985.91, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60985.91 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 33280.73, "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": 32113.25, "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": 58037.79 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 43264.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 41600.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60304.68, "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": 48589.87, "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": 46792.71, "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": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33280.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33703.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33280.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 51585.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 51585.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53249.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33280.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 57668.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31795.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58037.79 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4835.55, "additional_payer_notes": "107% 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": "FULL TERM NEONATE WITH MAJOR PROBLEMS", "code_information": [ { "code": "793", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42042, "minimum": 14311.5, "maximum": 76181.01, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76048.11 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 42042.5, "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": 40562.81, "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": 72885.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 54655.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 52553.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76181.01, "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": 61382.05, "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": 59111.76, "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": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 42042.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42570.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42042.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 65165.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 65165.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 67268, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42042.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 58582.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40161.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72885.84 } ] } ] }, { "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": 72028, "minimum": 41825.3088, "maximum": 130515.189, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 125016.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 72028.25, "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": 69479.82, "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": 116723.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 93636.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 90035.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 130515.19, "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": 105161.25, "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": 101271.72, "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": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 72028.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 72919.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 72028.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 111643.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 111643.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 115245.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 72028.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 43537.1 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 68791.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116723.96 } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12146, "minimum": 11616.2, "maximum": 22009.6936, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20614.09 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12146.63, "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": 11732.36, "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": 19891.78 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 15790.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15183.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22009.69, "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": 17734.08, "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": 17078.16, "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": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12146.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12313.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12146.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 18827.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18827.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19434.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12146.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20718.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11616.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19891.78 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70864.7, "additional_payer_notes": "107% 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": "FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CCMCC", "code_information": [ { "code": "929", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32568, "minimum": 22048.2, "maximum": 59014.6656, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58093.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 32568.8, "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": 31426.76, "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": 55582.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 42339.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 40711, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59014.67, "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": 47550.45, "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": 45791.73, "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": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32568.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32982.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32568.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 50481.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 50481.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52110.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32568.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22048.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31115.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55582.34 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10494.61, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41925.13, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 117818.2, "additional_payer_notes": "107% 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": "GASTROINTESTINAL HEMORRHAGE WITH MCC", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18661, "minimum": 17837, "maximum": 33815.1635, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32344.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18661.79, "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": 18015.37, "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": 31775.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 24260.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23327.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33815.16, "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": 27246.21, "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": 26238.48, "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": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18661.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18907.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18661.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 28925.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 28925.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29858.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18661.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21438.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17837, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31775.82 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES", "code_information": [ { "code": "748", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14261, "minimum": 13635.5, "maximum": 33342.8536, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25381.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14261.43, "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": 13771.86, "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": "case rate", "standard_charge_dollar": 23808.27 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 18539.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17826.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25841.71, "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": 20821.69, "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": 20051.57, "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": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14261.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14453.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14261.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 22105.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22105.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22818.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14261.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24402 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23808.27 } ] } ] }, { "description": "EXTRAOCULAR PROCEDURES EXCEPT ORBIT", "code_information": [ { "code": "115", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15735, "minimum": 15042.7, "maximum": 29466.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28263.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15735.21, "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": 15193.13, "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": 26756.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20455.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19669.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28512.2, "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": 22973.41, "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": 22123.71, "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": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15735.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15945.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15735.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24389.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24389.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25176.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15735.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29466.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15042.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26756.56 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITHOUT CCMCC", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6703, "minimum": 6419.4, "maximum": 12147.3581, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11439.83 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6703.84, "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": 6483.59, "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": 11127.3 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 8714.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8379.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12147.36, "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": 9787.61, "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": 9425.6, "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": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6703.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6804.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6703.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 10390.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10390.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10726.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6703.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8634.26 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6419.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11127.3 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.14, "additional_payer_notes": "107% 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": "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE", "code_information": [ { "code": "790", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59754, "minimum": 9294.84, "maximum": 108401.94, "payers_information": [ { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 77681.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 74693.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 108275.64, "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": 87241.96, "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": 84015.21, "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": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 59754.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60497.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59754.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 92619.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 92619.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 95607.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59754.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9294.84 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103894.44 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 108401.94 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 59754.77, "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": 57643.83, "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": "case rate", "standard_charge_dollar": 103894.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57073.1, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12320.85, "additional_payer_notes": "107% 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": "GASTROINTESTINAL OBSTRUCTION WITH CC", "code_information": [ { "code": "389", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8295, "minimum": 7308.06, "maximum": 15031.3373, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14388.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8295.44, "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": 8018.47, "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": "case rate", "standard_charge_dollar": 14009.18 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10784.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10369.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15031.34, "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": 12111.34, "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": 11663.39, "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": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8295.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8415.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8295.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 12857.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12857.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13272.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8295.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7308.06 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7939.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14009.18 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19116.48, "additional_payer_notes": "107% 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": "GASTROINTESTINAL OBSTRUCTION WITH MCC", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15155, "minimum": 14488.8, "maximum": 27461.005, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26259.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15155.08, "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": 14633.69, "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": 25688.74 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 19701.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18943.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27461, "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": 22126.42, "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": 21308.04, "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": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15155.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15358.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15155.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 23490.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 23490.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24248.13, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15155.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15834.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14488.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25688.74 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5081.7, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22679.33, "additional_payer_notes": "107% 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": "GASTROINTESTINAL OBSTRUCTION WITHOUT CCMCC", "code_information": [ { "code": "390", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5841, "minimum": 5416.19, "maximum": 10584.1457, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10099.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 5841.14, "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": 5651.65, "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": 9563.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 7593.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7301.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10584.15, "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": 8528.06, "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": 8212.64, "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": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5841.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5931.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5841.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 9053.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9053.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9345.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5841.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5416.19 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5595.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9563.15 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.45, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16847.87, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15753.26, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5169.04, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26664.15, "additional_payer_notes": "107% 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": "FOOT PROCEDURES WITH MCC", "code_information": [ { "code": "503", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 28278, "minimum": 27018.9, "maximum": 51240.2434, "payers_information": [ { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 36761.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 35347.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 51240.24, "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": 41286.29, "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": 39759.26, "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": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 28278.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28640.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 28278.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 43831.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 43831.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 45245.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 28278.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37175.6 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46253.37 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48453.05 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 28278.28, "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": 27289.09, "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": 46253.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27018.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": 10616, "minimum": 10155.7, "maximum": 41385.0834, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18816.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10616.93, "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": 10257.26, "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": 17819.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13802.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13271.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19237.88, "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": 15500.72, "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": 14927.4, "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": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10616.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10765.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10616.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 16456.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16456.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16987.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10616.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12324.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10155.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17819.06 } ] } ] }, { "description": "FOOT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "505", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18310, "minimum": 17501.4, "maximum": 33178.2998, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30816.35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18310.32, "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": 17676.41, "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": 30671.3 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 23803.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22887.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33178.3, "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": 26733.07, "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": 25744.31, "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": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18310.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18551.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18310.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 28381, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 28381, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29296.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18310.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18144.2 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17501.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30671.3 } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS", "code_information": [ { "code": "864", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9272, "minimum": 7992.68, "maximum": 19456.9238, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15949.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9272.96, "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": 8961.15, "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": 15693.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12054.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11591.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16802.6, "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": 13538.52, "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": 13037.78, "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": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9404.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14373.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14373.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14836.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7992.68 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8872.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15693.92 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10266.62, "additional_payer_notes": "107% 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": "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": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 36.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.53 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15076.08, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3624.11, "additional_payer_notes": "107% 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": "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": 16128, "minimum": 13275.5878, "maximum": 29286.1, "payers_information": [ { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16128.62, "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": 15572.48, "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": 26312.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20967.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20160.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29225.06, "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": 23547.79, "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": 22676.84, "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": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16128.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16343.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16128.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24999.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24999.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25805.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16128.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19665.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26312.65 }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29286.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15418.3, "additional_payer_notes": "100.00% of Medicare 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": 4132, "maximum": 14807.6, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5186.54, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6431.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6431.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8992.78, "additional_payer_notes": "107% 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": "HAND PROCEDURES FOR INJURIES", "code_information": [ { "code": "906", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20022, "minimum": 19136.5, "maximum": 49857.1498, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33994.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20022.74, "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": 19327.87, "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": 38142.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 26029.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25028.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36281.2, "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": 29233.2, "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": 28151.97, "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": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20022.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20284.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20022.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 31035.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31035.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32036.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20022.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23560.4 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19136.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38142.51 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.57 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 } ] } ] }, { "description": "FRACTURES OF FEMUR WITHOUT MCC", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8458, "minimum": 6570.29, "maximum": 16648.052, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14634.02 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8458.19, "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": 8175.42, "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": 14225.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 10995.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10572.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15326.24, "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": 12348.96, "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": 11892.22, "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": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8458.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8580.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8458.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 13110.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13110.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13533.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8458.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6570.29 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8094.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14225.89 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8663.83, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29739.26, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8599.18, "additional_payer_notes": "107% 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 HEMORRHAGE WITH CC", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10201, "minimum": 9759.07, "maximum": 18485.2267, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17774.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10201.56, "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": 9856.66, "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": 17230.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 13262.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12751.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18485.23, "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": 14894.28, "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": 14343.39, "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": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10201.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10344.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10201.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 15812.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15812.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16322.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10201.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11067.8 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9759.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17230.11 } ] } ] }, { "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": 9350, "minimum": 8946.8, "maximum": 20045.1896, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16180.53 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9350.84, "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": 9036.27, "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": 15620.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 12156.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11688.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16943.72, "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": 13652.23, "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": 13147.28, "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": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9350.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9483.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9350.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 14493.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14493.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14961.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9350.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9307.5 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8946.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15620.52 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5518.41, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4623.44, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9658.62, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6196.72, "additional_payer_notes": "107% 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": "FRACTURES OF FEMUR WITH MCC", "code_information": [ { "code": "533", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16062, "minimum": 10468.0146, "maximum": 29474, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29474 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16062.71, "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": 15508.95, "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": 26649.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 20881.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20078.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29105.63, "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": 23451.56, "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": 22584.17, "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": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16062.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16276.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16062.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 24897.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 24897.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25700.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16062.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21419.3 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15355.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26649.95 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7582.84, "additional_payer_notes": "107% 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": "Fth gr fccmnaxghf ea", "code_information": [ { "code": "15241", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3587.5, "minimum": 213.61, "maximum": 3587.5, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 228.56 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 213.61 } ] }, { "setting": "outpatient", "gross_charge": 3587.5, "minimum": 213.61, "maximum": 3587.5, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 228.56 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 213.61 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 346.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY", "code_information": [ { "code": "934", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22482, "minimum": 4606.29, "maximum": 40737.4384, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37804.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22482.03, "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": 21699.45, "additional_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": 37501.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "case rate", "standard_charge_dollar": 29226.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28102.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40737.44, "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": 32823.76, "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": 31609.73, "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": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22482.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22773.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22482.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "case rate", "standard_charge_dollar": 34847.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 34847.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35971.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22482.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4606.29 }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21484.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37501.13 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6774.08, "additional_payer_notes": "107% 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": "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14184.51, "additional_payer_notes": "107% 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 (Sup Shell A4223) Infusion Supplies W/O Pump", "code_information": [ { "code": "A4223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 1232.82, "10th_percentile": 1232.82, "90th_percentile": 1554.82, "count": "1 through 10" } ] } ] }, { "description": "Hc (Sup Shell A4213) 20+ Cc Syringe Only", "code_information": [ { "code": "A4213", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "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": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 565.36, "10th_percentile": 373.81, "90th_percentile": 5906.69, "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 Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 381.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1254.14, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1555.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1555.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.54 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1799.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1799.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 97.83, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 66.99 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% 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": 6.1, "maximum": 64.4, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.53 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.96, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.79 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 80.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.02 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 99.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 99.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "125.00% 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% 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": 14437.5, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Anesth Vag Delivery, Epidural", "code_information": [ { "code": "01967", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1151.33, "minimum": 77.11, "maximum": 1151.33, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.51 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.41 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.57 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 2373.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2373.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.21, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 62.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 62.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.36, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.19 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "125.00% 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": 72.5, "10th_percentile": 72.5, "90th_percentile": 72.5, "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": 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 28.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.45 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1799.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1799.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.12 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Verda Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 353.07 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.11, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.71 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 630, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 781.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 781.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 33.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.48 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 40.78, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.93 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 50.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.29 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 350.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 1319.25, "10th_percentile": 1319.25, "90th_percentile": 1357.84, "count": "1 through 10" }, { "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 434.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 434.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 42.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.83 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 52.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 52.61, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.05 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.57 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.54 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 35.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 35.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "125.00% 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 Medicare", "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 Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.88 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 159.17 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.78, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.32 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.77 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 243.36 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Arc Frozen Blood,Freezing", "code_information": [ { "code": "86930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 218, "minimum": 84.6, "maximum": 380.35, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.12 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.96, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.96 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13.59, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.59, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.5 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.12 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 374.88 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.56 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 2373.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2373.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.61 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.99, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.5 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 264.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 264.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 52.66, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.08 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 65.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 65.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.95 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.61 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 24.96, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.96, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 375, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 465, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 465, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.42 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.04 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 80.24, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.88 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 99.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 99.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12478.14, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1098.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Verda Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 90.03 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1404.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1404.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 404.69, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 501.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 501.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 407.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 504.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 504.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 493.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 } ] } ] }, { "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": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "155.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 28.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 64.1, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.77 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 79.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 79.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 16.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 27.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.18 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.83 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 205.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.72 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 255.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 255.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.56, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.21, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.3 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 8.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.91 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 } ] } ] }, { "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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 108.7, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.44 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 134.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 134.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 189.61 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 184.04 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "fee schedule", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3737.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3737.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4.91, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.81 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "155.00% 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.04 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 345.44, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 428.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 428.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.49, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.99 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": 349.63, "10th_percentile": 349.63, "90th_percentile": 349.63, "count": "1 through 10" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 126.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.86 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.96, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.37 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 25.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 48.28, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.15 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 59.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.86, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.15 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% 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 Medicare", "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 Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 21.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.15 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 39.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 39.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.72 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2572.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3189.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3189.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 30.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 30.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.94, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 63.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 63.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 711.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 711.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.55 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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" }, { "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 209.7 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 36.04, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 44.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 44.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 309.12 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.56 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Androsterone", "code_information": [ { "code": "82160", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 272.24, "discounted_cash": 25, "minimum": 25.51, "maximum": 272.24, "payers_information": [ { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.94, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.3 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 39.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 39.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.08, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.81 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.57 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.41 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.36, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.15 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 32.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.84, "additional_payer_notes": "106.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.51 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.2 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 8.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.35 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": 6.98, "maximum": 119.28, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 29.55, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 36.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 36.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.29 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 711.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 711.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.07 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 8.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.97 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 33.49, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.23 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 41.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 41.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.52 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 117.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 133.01 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.1, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.93 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 21.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 46.28, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 57.38, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 57.38, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.35, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.39 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 28.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.48 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 114.47 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.34, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.99 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.73 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 16.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 57.89, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.63 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 71.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 71.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.35, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 31.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.71 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.21 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.84 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.5 }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.1 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 148.88, "10th_percentile": 148.88, "90th_percentile": 148.88, "count": "1 through 10" }, { "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.57 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 } ] } ] }, { "description": "Hc Assay Of Amikacin", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 272.5, "discounted_cash": 15, "minimum": 15.08, "maximum": 272.5, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 165.71 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1844.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1844.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.62 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.36 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 102.35, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 126.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 126.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 29.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 29.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.76 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": 94.87, "10th_percentile": 94.87, "90th_percentile": 94.87, "count": "1 through 10" } ] } ] }, { "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": "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.97 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "125.00% 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 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.82 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 21.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.1, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.67 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.97 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.48, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 25.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.54, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "Keenan", "plan_name": "Keenan", "methodology": "percent of total billed charges", "standard_charge_percentage": 30, "median_amount": 355.85, "10th_percentile": 355.85, "90th_percentile": 355.85, "count": "1 through 10" }, { "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 30.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 30.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.81, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.86, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.59 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.07 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 16.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 101.71 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.73, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.09 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 186.28 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.14, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.59 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 9.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.13 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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" }, { "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.07 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.86 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Lead", "code_information": [ { "code": "83655", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60.55, "discounted_cash": 12, "minimum": 12.11, "maximum": 60.55, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 12.2 }, { "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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.84, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 47.16, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 58.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 58.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "125.00% 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": 4.86, "10th_percentile": 4.86, "90th_percentile": 68.27, "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": 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.1, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 51.76, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.38 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.36, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.15, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.58 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 34.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 34.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.8, "additional_payer_notes": "125.00% 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 }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "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": "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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Magnesium", "code_information": [ { "code": "83735", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 193.77, "discounted_cash": 6, "minimum": 6.7, "maximum": 193.77, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "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": 10.05, "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": 6.77, "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": 8.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.32 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.83, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 30.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 30.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Methadone - G0480 - 30100205", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 199.98, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.29 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 12.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "125.00% 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 } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.6, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Nucleotidase 5'", "code_information": [ { "code": "83915", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.95, "discounted_cash": 11, "minimum": 11.15, "maximum": 136.95, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "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": 11.26, "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": 14.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.17 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.01, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.89 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 32.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": 47.79, "maximum": 380.35, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Osteocalcin", "code_information": [ { "code": "83937", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 144, "discounted_cash": 29, "minimum": 29.85, "maximum": 144, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "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": 44.78, "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": 30.15, "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": 39.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 41.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 37.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 41.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 46.27, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 46.27, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 39.32, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 30.23, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.39 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Arc Frozen Blood Thaw Per Unit", "code_information": [ { "code": "86931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 625.6, "discounted_cash": 218, "minimum": 187.68, "maximum": 625.6, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Phenobarbital", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 341.55, "discounted_cash": 15, "minimum": 9.64, "maximum": 341.55, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "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": 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": 15.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.19, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.23 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 38.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 38.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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 Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 83.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.19 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 103.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 103.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Phenytoin, Total", "code_information": [ { "code": "80185", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 391.23, "discounted_cash": 13, "minimum": 13.25, "maximum": 391.23, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.52 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.52 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.56, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 20.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.54, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 13.52 }, { "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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.38, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.13 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": 94.87, "10th_percentile": 94.87, "90th_percentile": 94.87, "count": "1 through 10" } ] } ] }, { "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% 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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 337.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Porphyrins Urine Quan&Fxj", "code_information": [ { "code": "84120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 274.52, "discounted_cash": 14, "minimum": 14.71, "maximum": 274.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "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": 22.07, "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": 14.86, "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": 19.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 20.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.06 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "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": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.99, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "125.00% 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 Medicare", "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 Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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,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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Pregnanetriol", "code_information": [ { "code": "84138", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172.5, "discounted_cash": 21, "minimum": 19.32, "maximum": 172.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "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": 31.58, "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": 21.26, "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": 27.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.32 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 19.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 29.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.67 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.73, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Endocrine Hormone", "code_information": [ { "code": "84235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 427.38, "discounted_cash": 71, "minimum": 65.39, "maximum": 427.38, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "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": 106.85, "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": 71.94, "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": 93.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 99.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 89.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 104 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 100.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.97 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 110.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 110.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.83, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.63, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 23.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1129.29, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.2 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1400.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1400.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" } ] } ] }, { "description": "Hc Assay Of Primidone", "code_information": [ { "code": "80188", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 241.25, "discounted_cash": 16, "minimum": 16.59, "maximum": 241.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.76, "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": "fee schedule", "standard_charge_dollar": 21.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.93 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 25.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Estrogens", "code_information": [ { "code": "82671", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 62.5, "discounted_cash": 32, "minimum": 18.75, "maximum": 62.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "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": 48.45, "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": 32.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 45.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 40.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 45.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.26 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 50.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.55, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 80.51, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.1 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 99.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 99.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.36 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Progesterone Receptor", "code_information": [ { "code": "84234", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 64, "minimum": 60.97, "maximum": 286, "payers_information": [ { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "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": 97.32, "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": 65.53, "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": 85.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 90.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 81.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 91.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.24 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 100.56, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 100.56, "additional_payer_notes": "155.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ethosuximide", "code_information": [ { "code": "80168", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.24, "discounted_cash": 16, "minimum": 6.672, "maximum": 22.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.5, "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": 21.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 22.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.83 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.53, "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": 11.2, "maximum": 152.4, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.22 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 17.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Prostate Specific Antigen Total - 84153 - 30100312", "code_information": [ { "code": "84153", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 376.17, "discounted_cash": 18, "minimum": 18.39, "maximum": 376.17, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "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": 27.59, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "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": 24.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 25.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.07 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.49, "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": 181.18, "10th_percentile": 181.18, "90th_percentile": 181.18, "count": "1 through 10" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 28.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Fentanyl - G0480 - 30100020", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 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": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.84 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.6, "additional_payer_notes": "140.00% 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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 57.58 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Quinidine", "code_information": [ { "code": "80194", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 220.5, "discounted_cash": 14, "minimum": 14.6, "maximum": 220.5, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.25, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Assay Of Folic Acid, Rbc", "code_information": [ { "code": "82747", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 216.75, "discounted_cash": 17, "minimum": 13.19, "maximum": 216.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "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": 26.48, "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": 17.83, "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": 23.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 24.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.11 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 27.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.25, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 36.91, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.23 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 45.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 45.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Asp & Inj Bone Cyst", "code_information": [ { "code": "20615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2896.7, "discounted_cash": 906, "minimum": 241.91, "maximum": 2896.7, "payers_information": [ { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 1404.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1404.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 241.91 }, { "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 Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Serotonin", "code_information": [ { "code": "84260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 217.3, "discounted_cash": 30, "minimum": 30.98, "maximum": 217.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 39.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "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": 46.47, "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": 31.29, "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": 40.81, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 43.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 38.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 45.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 43.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.81 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 48.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 48.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.81, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of For Hva", "code_information": [ { "code": "83150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 236.97, "discounted_cash": 22, "minimum": 13.08, "maximum": 236.97, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "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": 33.62, "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": 22.63, "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": "fee schedule", "standard_charge_dollar": 29.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 31.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 34.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 34.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.52, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Aspa Gene", "code_information": [ { "code": "81200", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 556, "discounted_cash": 47, "minimum": 47.25, "maximum": 556, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 60.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "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": 70.88, "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": 47.72, "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": 62.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 66.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 68.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 66.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 73.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 73.24, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Sialic Acid", "code_information": [ { "code": "84275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.29, "discounted_cash": 13, "minimum": 5.487, "maximum": 18.29, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": 18.29, "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": 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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.29 }, { "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": "Health Net Of CA", "plan_name": "Health Net Of 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Assay Of Free Thyroxine", "code_information": [ { "code": "84439", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 328.31, "discounted_cash": 9, "minimum": 9.02, "maximum": 328.31, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "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": 13.53, "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": 9.11, "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": 11.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 12.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Aspirat/Injection Ganglion Cyst(S)", "code_information": [ { "code": "20612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1585.23, "discounted_cash": 392, "minimum": 54.36, "maximum": 1585.23, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.17 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 54.36 }, { "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 Health Plan", "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 Of Sweat Sodium", "code_information": [ { "code": "84302", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.6, "discounted_cash": 4, "minimum": 3.46, "maximum": 48.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "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": 7.29, "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": 4.91, "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": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.7 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Gammaglobulin Iga, Igd, Igg, Igm, Each", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 123.46, "discounted_cash": 9, "minimum": 6.98, "maximum": 123.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "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": 13.95, "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": 9.39, "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": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 13.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ldh Isoenzymes", "code_information": [ { "code": "83625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.42, "discounted_cash": 12, "minimum": 5.226, "maximum": 17.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "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": 17.42, "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": 12.92, "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": 16.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Blood Carbon Monoxide", "code_information": [ { "code": "82375", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 307.5, "discounted_cash": 12, "minimum": 12.32, "maximum": 307.5, "payers_information": [ { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "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": 18.48, "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": 12.44, "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": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.25, "additional_payer_notes": "140.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Testosterone", "code_information": [ { "code": "84402", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 258.1, "discounted_cash": 25, "minimum": 25.47, "maximum": 258.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "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": 38.21, "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": 25.72, "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": 33.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.98 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 25.98 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 35.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.8 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 39.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 39.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Gammaglobulin Ige", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.46, "discounted_cash": 16, "minimum": 4.938, "maximum": 16.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "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": 16.46, "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": 16.46, "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": 16.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "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": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Manganese", "code_information": [ { "code": "83785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.5, "discounted_cash": 26, "minimum": 25.08, "maximum": 146.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "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": 39.98, "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": 26.92, "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": 35.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 37.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 37.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 41.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 41.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.11, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Growth Hormone (Hgh)", "code_information": [ { "code": "83003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 208.38, "discounted_cash": 16, "minimum": 16.67, "maximum": 208.38, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "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": 25.01, "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": 16.84, "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": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 25.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Theophylline", "code_information": [ { "code": "80198", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 282, "discounted_cash": 14, "minimum": 14.14, "maximum": 282, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "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": 21.21, "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": 14.28, "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": 18.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.63, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ggt", "code_information": [ { "code": "82977", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 90, "discounted_cash": 7, "minimum": 7.2, "maximum": 90, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "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": 10.8, "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": 7.27, "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": 9.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 10.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Methemalbumin", "code_information": [ { "code": "83857", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160.82, "discounted_cash": 10, "minimum": 10.74, "maximum": 160.82, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 10.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 16.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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": 10.95 }, { "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 Health Plan", "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 17-Hydroxypregneno", "code_information": [ { "code": "84143", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 248.4, "discounted_cash": 22, "minimum": 22.81, "maximum": 248.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "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": 34.22, "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": 23.04, "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": 30.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 31.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 35.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 35.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Thiocyanate", "code_information": [ { "code": "84430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71, "discounted_cash": 11, "minimum": 11.63, "maximum": 71, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "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": 17.45, "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": 11.75, "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": 15.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 16.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.7 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 18.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Glucosidase", "code_information": [ { "code": "82963", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 263.16, "discounted_cash": 21, "minimum": 21.48, "maximum": 263.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "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": 32.22, "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": 21.69, "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": 28.3, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 30.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.45 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 33.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 33.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Androstenedione", "code_information": [ { "code": "82157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 255.5, "discounted_cash": 29, "minimum": 29.28, "maximum": 255.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "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": 43.92, "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": 29.57, "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": 38.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 40.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 36.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 41.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.95 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 45.38, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 45.38, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Thyroid Stim Immunoglobulins (Tsi)", "code_information": [ { "code": "84445", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "discounted_cash": 50, "minimum": 50.86, "maximum": 200, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 64.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "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": 76.29, "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": 51.37, "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": 67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 71.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 63.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 71.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.5 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 53.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 78.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 78.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Haptoglobin, Quant", "code_information": [ { "code": "83010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 110.08, "discounted_cash": 12, "minimum": 12.58, "maximum": 110.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_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": 12.71, "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": "fee schedule", "standard_charge_dollar": 16.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 17.61, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.49 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 19.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Angiotensin Ii", "code_information": [ { "code": "82163", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251.37, "discounted_cash": 20, "minimum": 20.52, "maximum": 251.37, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "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": 30.78, "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": 20.73, "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": 27.03, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 28.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 31.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.03, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Thyroxine Bndng Globulin", "code_information": [ { "code": "84442", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 147.8, "discounted_cash": 14, "minimum": 14.78, "maximum": 147.8, "payers_information": [ { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Assay Of Opiates - G0480 - 30100328", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 B Hexosaminidase", "code_information": [ { "code": "83080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.55, "discounted_cash": 16, "minimum": 16.87, "maximum": 206.55, "payers_information": [ { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% 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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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" }, { "payer_name": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Total Testosterone", "code_information": [ { "code": "84403", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 417.82, "discounted_cash": 25, "minimum": 25.81, "maximum": 417.82, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "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": 38.72, "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": 26.07, "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": "fee schedule", "standard_charge_dollar": 34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 36.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.99 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 40.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 40.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Inorganic Phosphorus", "code_information": [ { "code": "84100", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249.78, "discounted_cash": 4, "minimum": 4.74, "maximum": 249.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "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": 7.11, "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": 4.79, "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": 6.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.17 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 7.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Porphobilinogen Urine Quan", "code_information": [ { "code": "84110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 490.55, "discounted_cash": 8, "minimum": 8.44, "maximum": 490.55, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "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": 12.66, "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": 8.52, "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": 11.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 11.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Benzodiazepines - G0480 - 30100410", "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": "Aetna", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "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": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "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", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "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 Medicare", "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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "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": "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 177.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar 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 Health Plan", "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 Total Thyroxine", "code_information": [ { "code": "84436", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 274.24, "discounted_cash": 6, "minimum": 5.94, "maximum": 274.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry fka Aetna Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "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": 10.31, "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": 6.94, "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": 9.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Pace Cal Medi Connect", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare Surgery Plus", "plan_name": "Employer Direct Healthcare Surgery Plus", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.36 }, { "payer_name": "Health Net of CA MHN (BH)", "plan_name": "Health Net of CA MHN (BH) Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA Inc", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NAPHCARE (Santa Ana - County Jail)", "plan_name": "Naphcare Prison (Santa Ana - County Jail)", "methodology": "fee schedule", "standard_charge_dollar": 10.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Naphcare Residential Treatment Center", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solutions", "plan_name": "Renal Payar Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda Health Plan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Insulin,Total", "code_information": [ { "code": "83525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.88, "discounted_cash": 11, "minimum": 9.18, "maximum": 142.88, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare (9/16/2021 to 12/31/2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of CA Triwest", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "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": 17.15, "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": 11.54, "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": 15.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Cal Optima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "Caloptima", "plan_name": "Cal Op